Medical Professionalism Best Practices

Medical Professionalism Best Practices
,
Medical Professionalism
Best Practices
Edited by
Richard L. Byyny, MD
Maxine A. Papadakis, MD
Douglas S. Paauw, MD
2015
Alpha Omega Alpha Honor Medical Society
Menlo Park, California
A A
1902
Medical Professionalism
Best Practices
Edited by
Richard L. Byyny, MD
Maxine A. Papadakis, MD
Douglas S. Paauw, MD
2015
Alpha Omega Alpha Honor Medical Society
Menlo Park, California
i
Dedicated to the members of Alpha Omega Alpha Honor
Medical Society and the medical profession
Publication of this monograph was funded by a President’s Grant from the
Josiah Macy Jr. Foundation.
Medical Professionalism: Best Practices
Edited by Richard L. Byyny, MD; Maxine A. Papadakis, MD;
Douglas S. Paauw, MD
© 2015, Alpha Omega Alpha Honor Medical Society
ISBN: 978-0-578-16071-9
eBook ISBN: 978-0-578-16072-6
ii
Contributors
Richard L. Byyny, MD (AΩA, University of Southern California, 1964),
is the Executive Director of Alpha Omega Alpha Honor Medical Society,
and was previously Professor of Medicine at the University of Colorado
School of Medicine. From 1997 through 2005, Dr. Byyny served as the
Chancellor of the University of Colorado at Boulder. Contact Dr. Byyny
at: Alpha Omega Alpha, 525 Middlefield Road, Suite 130, Menlo Park,
California 94025. E-mail: [email protected]
Anna Chang, MD (AΩA, St. Louis University, 2000), is Associate
Professor of Medicine in the Division of Geriatrics, Department of
Medicine, at the University of California, San Francisco, School of
Medicine. Contact Dr. Chang at: University of California, San Francisco,
School of Medicine, 3333 California Street, Laurel Heights, Room 380, San
Francisco, California 94118. E-mail: [email protected]
William O. Cooper, MD, MPH, is Cornelius Vanderbilt Professor
and Associate Dean for Faculty Affairs at Vanderbilt University School
of Medicine and the Director of the Vanderbilt Center for Patient and
Professional Advocacy. Contact Dr. Cooper at: Center for Patient and
Professional Advocacy, Vanderbilt University medical Center, 2135
Blakemore Avenue, Nashville, Tennessee 37212-3505. E-mail: william.
[email protected]
Richard M. Frankel, PhD, is Professor of Medicine and Geriatrics at the
Indiana University School of Medicine, Director of the Mary Margaret
Walther Program in Palliative Care Research and Education at the IU/
Simon Cancer Center, and Associate Director of the VA HSR&D Center
for Health Information and Communication. Contact Dr. Frankel at:
Veterans Administration Medical Center, Room 11 HSR&D, 1481 West
10th Street, Indianapolis, Indiana 46202-2884. E-mail: [email protected]
Suely Grosseman, MD, PhD, is Professor of Pediatrics at the Federal
University of Santa Catarina (Brazil). Contact Dr. Grosseman at:
Universidade Federal de Santa Catarina—Campus Reitor João David
Ferreira Lima Centro de Ciências da Saúde, Departamento de Pediatria
Florianópolis, Santa Catarina, Brasil CEP: 88040-900. E-mail: [email protected]
Gerald B. Hickson, MD, is Assistant Vice Chancellor for Health Affairs
and Senior Vice President of Quality, Safety and Risk Prevention at
Vanderbilt University School of Medicine. Contact Dr. Hickson at: Quality
and Patient Safety, 2135 Blakemore Avenue, Campus Zip 8627, Nashville,
Tennessee 37212. E-mail: [email protected]
Catherine R. Lucey, MD (AΩA, Northwestern University, 1980),
is Professor of Medicine and Vice Dean for Medical Education at the
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University of California, San Francisco, School of Medicine. Contact Dr.
Lucey at: University of California, San Francisco, School of Medicine,
Box 0410, 521 Parnassus Avenue, Clinic Sci Room 254, San Francisco,
California 94143. E-mail: [email protected]
Dennis H. Novack, MD (AΩA, Drexel University, 2001), is Professor of
Medicine and Associate Dean of Medical Education at Drexel University
College of Medicine. He is a 2011 recipient of the AΩA Robert J. Glaser
Distinguished Teacher Award. Contact Dr. Novack at: Drexel University
College of Medicine, 2126 Fairmount Avenue, Philadelphia, Pennsylvania
19130. E-mail: [email protected]
Douglas S. Paauw, MD (AΩA, University of Michigan, 1983), is Director,
Medicine Student Programs, Professor of Medicine, and Rathmann Family
Foundation Endowed Chair in Patient-Centered Clinical Education at
the University of Washington School of Medicine. He is a 2001 recipient of the AΩA Robert J. Glaser Distinguished Teacher Award, President
of the Board of Directors of Alpha Omega Alpha, and AΩA councilor
at the University of Washington. Contact Dr. Paauw at: University of
Washington School of Medicine, Department of Internal Medicine, Box
356420, 1959 NE Pacific Street, Seattle, Washington 98195-6420. E-mail:
[email protected]
Maxine Papadakis, MD (AΩA, University of California, San Francisco,
1993), is Professor of Medicine and Associate Dean for Students at
the University of California, San Francisco, School of Medicine. She
was member of the Board of Directors of Alpha Omega Alpha from
2005 through 2007. Contact Dr. Papadakis at: University of California,
San Francisco, School of Medicine, 513 Parnassus Avenue, S-245, San
Francisco, California 94143-0454. E-mail: [email protected]
Sheryl A. Pfeil, MD (AΩA, Ohio State University, 1984), is Associate
Professor of Clinical Internal Medicine and Medical Director of the
Clinical Skills Education and Assessment Center at Ohio State University
College of Medicine. She is a member of the Board of Directors of Alpha
Omega Alpha and the AΩA councilor at Ohio State. Contact Dr. Pfeil
at: Ohio State University, Division of Gastroenterology, Hepatology and
Nutrition, 395 W. 12th Avenue, Suite 200, Columbus, Ohio 43210. E-mail:
[email protected]
Rebecca Saavedra, EdD, is Vice President of Strategic Management in
the Office of the President, and Co-Chair of the UTMB Professionalism
Committee. Contact Dr. Saavedra at: The University of Texas Medical
Branch at Galveston, Office of the President Mail Route 0127, 301
University Boulevard, Galveston, Texas 77555-0127. E-mail: [email protected]
utmb.edu.
Jo Shapiro, MD (AΩA, George Washington University, 1980), is
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Associate Professor of Otolaryngology at Harvard Medical School and
Director of the Center for Professionalism and Peer Support and Chief of
the Division of Otolaryngology in the Department of Surgery at Brigham
and Women’s Hospital. Contact Dr. Shapiro at: Brigham and Women’s
Hospital, Division of Otolaryngology, 45 Francis Street, ASB-2, Boston,
Massachusetts 02115. E-mail: [email protected]
George Thibault, MD (AΩA, Harvard Medical School, 1968), has
served as the President of the Josiah Macy Jr. Foundation since 2008. He
is the Daniel D. Federman Professor of Medicine and Medical Education,
Emeritus, at Harvard Medical School. He was previously Vice President
of Clinical Affairs at Partners Healthcare System in Boston and Director
of the Academy at Harvard Medical School. Contact Dr. Thibault at: The
Josiah Macy Jr. Foundation, 44 East 64th Street, New York, New York
10065. E-mail: [email protected]
Deborah Ziring, MD, is Assistant Professor in the Department of
Medicine at Drexel University College of Medicine. Contact Dr. Ziring
at: Drexel University College of Medicine, 2900 Queen Lane, Room 221,
Philadelphia, Pennsylvania 19129. E-mail: [email protected]
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Acknowledgments
Thanks to Dr. John A. Benson, Jr. (AΩA, Oregon Health & Science
University, 1968), and Dr. Jack Coulehan (AΩA, University of Pittsburgh,
1969), who serve on AΩA’s Professionalism Award Committee and on the
editorial board of The Pharos, for their help in reviewing and improving
this monograph.
We thank the Josiah Macy Jr. Foundation for its President’s Grant,
which funded the publication and distribution of this monograph.
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Table of Contents
Dedication...........................................................................................................
Contributors .......................................................................................................
Acknowledgments .............................................................................................
Preface. Medical Professionalism: Best Practices
Richard L. Byyny, MD .......................................................................................
Introduction ...........................................................................................
Chapter . Introduction
Maxine Papadakis, MD ...............................................................................
Chapter . The Problem with Professionalism
Catherine R. Lucey, MD ...............................................................................
Chapter . Current Practices in Remediating Medical Students
with Professionalism Lapses
Deborah Ziring, MD, Suely Grosseman, MD, PhD,
and Dennis Novack, MD ...........................................................................
Models .....................................................................................................
Chapter . Review of Current Models for Remediation of
Professionalism Lapses
Sheryl A. Pfeil, MD, and Douglas S. Paauw, MD .....................................
Chapter . Cultural Transformation in Professionalism
Jo Shapiro, MD ...............................................................................................
Chapter . Enhancing Interprofessional Professionalism:
A Systems Approach
Rebecca Saavedra, EdD ................................................................................
Chapter . Pursuing Professionalism
(But not without an infrastructure)
Gerald B. Hickson, MD, and William O. Cooper, MD, MPH ................
Remediation ...........................................................................................
Chapter . Clinical Skills Remediation: Strategy for
Intervention of Professionalism Lapses
Anna Chang, MD ..........................................................................................
Chapter . Remediating Professional Lapses of Medical Students:
Each School an Island?
Richard Frankel, PhD ....................................................................................
Summary .................................................................................................
Chapter . Concluding Thoughts
George Thibault, MD ....................................................................................
Chapter . Improving Professionalism in Medicine:
What Have We Learned?
Sheryl A. Pfeil, MD ........................................................................................
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Preface
Medical Professionalism: Best Practices
Richard L. Byyny, MD
P
rofessionalism in medicine has been a core value for Alpha Omega
Alpha Honor Medical Society (AΩA) since the society’s founding in 1902. Demonstrated professionalism is one of the criteria
for election to membership in AΩA. In the Winter 2000 issue of AΩA’s
quarterly journal The Pharos, Executive Director Edward D. Harris, Jr.,
MD (1997–2010), wrote, “The profession of medicine is under siege. Our
resistance must be professionalism.” In 2009, AΩA established an annual
Edward D. Harris Professionalism Award that encourages teaching faculty
to create appropriate learning environments for professionalism, or new
programs to ingrain professionalism in medical students and resident physicians. Since then, AΩA has made annual awards and continued its work
to promote, understand, and support medical professionalism.
Because medical professionalism is a core value of the society, the board
of directors of AΩA has discussed how the society can serve as a leader
and a catalyst to improve medical professionalism. We wanted to better
understand medical professionalism, professionalism issues, and learn
about teaching and supporting research and scholarship related to medical
professionalism, identifying methods of evaluating aspects of professionalism, and finding a leadership focus for AΩA in medical professionalism.
In 1914, U.S. Supreme Court Justice Louis Brandeis defined a profession:
First. A profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge, and to some extent learning,
as distinguished from mere skill.
Second. A profession is an occupation which is pursued largely for others and
not merely for one’s self.
Third. It is an occupation in which the amount of financial return is not the
accepted measure of success.
Our efforts in medical professionalism are a work in progress. As physicians, we are gradually and continually learning about medical professionalism and how to maintain and improve a standard of physician behavior.
We need to remember that we call our work “the practice of medicine”
because we are always practicing our profession to learn and improve.
We also need to remember that our goal is not perfection, but continuous
learning, improvement, and focusing on what is best for the patient. We
recognize medical professionalism as an important issue for doctors and
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Medical Professionalism: Best Practices
society that must be taught and then practiced in the interests of both
patients and our profession.
We have begun to make progress, but the challenges are huge. Since
AΩA developed the Edward D. Harris Professionalism Award a few years
ago as our society’s contribution to promote professionalism in medicine,
we have made awards for some interesting projects but haven’t had a clear
focus about AΩA’s leadership role and how the society’s programs and
projects can make a positive difference in medical professionalism—is it
in curriculum reform, remediation, or some other important step toward
the future?
We are committed to focusing our efforts at AΩA to define our role in
the development of professionalism in medicine. Many AΩA members are
leaders in medicine. We recognize that developing effective leadership in
medicine must continue to be grounded in professional values. It is clear
that the combination of leadership and professionalism can have a synergistic and positive impact on our members and profession.
To learn more about medical professionalism, we sponsored and hosted
an AΩA Think Tank Meeting on Medical Professionalism in July 2011. We
brought together experts in medical professionalism to review and discuss
the status of and challenges in the field. That meeting was based on the
assumption that the last twenty years have seen good progress in defining
professionalism and in devising charters, curricula, assessment strategies, and accreditation criteria. However, participants recognized that
there has been insufficient evidence to inform best practices in medical
professionalism. This is especially true for interventions and remediation
strategies for those who demonstrate lapses in professionalism and professional behaviors. The meeting resulted in the publication in Academic
Medicine of “Perspective: The Education Community Must Develop Best
Practices Informed by Evidence-based Research to Remediate Lapses of
Professionalism.” 1 The meeting participants identified two issues as very
important to medical professionalism:
1. How can we use existing data on professionalism remediation?
2. What new evidence is needed to advance approaches to remediation
of unprofessional performance?
Participants also recommended that the education community focus
on interventions and remediation by performing studies about improving
medical professionalism when lapses occur, identifying best evidencebased remediation practices, widely disseminating those practices, and
moving over time from a best-practice approach to remediation (which
does not yet exist) to a best-evidence model.
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Preface: Medical Professionalism: Best Practices
This monograph, Medical Professionalism: Best Practices, is the result of a subsequent AΩA sponsored meeting, Best Practices in Medical
Professionalism, which had two themes:
1. Use of systems to enhance professionalism
2. Best practices for the remediation of lapses in professionalism
The authors in this monograph presented some of the identified best
practices, followed by discussion, questions, and debate. We thank the
Josiah Macy Jr. Foundation for its President’s Grant, which funds the publication and distribution of this monograph. The Foundation’s president,
Dr. George E. Thibault, participated in our meeting and has written the
concluding chapter.
The co-chairs of the meeting, co-editors of this monograph, and authors of two chapters are Dr. Maxine Papadakis and Dr. Douglas S. Paauw.
AΩA and medical professionalism
Medicine is based on a covenant of trust, a contract we in medicine
have with patients and society. Medical professionalism stands on the
foundation of trust to create an interlocking structure among physicians,
patients, and society that determines medicine’s values and responsibilities in the care of the patient and improving public health. AΩA supports
and advocates for medical professionalism as a core value of the society.
The founding of AΩA is interesting and important to medical professionalism. William Root and other medical students at the College of
Physicians and Surgeons of Chicago founded AΩA in 1902, before the
Abraham Flexner report and the subsequent transformation of medical
education. Root and likeminded fellow students were shocked by the lack
of interest in high achievement, especially high academic achievement, by
the faculty and their fellow students. They found the behavior of students
and faculty to be boorish and clearly lacking in professional values. They
decided to establish a medical honor society based on the model of Phi
Beta Kappa. They wrote, “The mission of AΩA is to encourage high ideals
of thought and action in schools of medicine and to promote that which
is the highest in professional practice.” They defined the duties of AΩA
members: “to foster the scientific and philosophical features of the medical profession and of the public, to cultivate social mindedness as well
as an individualistic attitude toward responsibilities, to show respect for
colleagues and especially for elders and teachers, to foster research, and
in all ways to strive to ennoble the profession of medicine and advance it
in public opinion. It is equally a duty to avoid what is unworthy, including the commercial spirit and all practices injurious to the welfare of
patients, the public or the profession.” They established the AΩA motto:
“Be worthy to serve the suffering.” Since its founding, AΩA has celebrated,
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Medical Professionalism: Best Practices
advocated, and supported the principles of high academic achievement,
leadership, demonstrated professionalism, service, research and scholarship, and teaching in medicine. Election to membership in AΩA is based
on outstanding scholarly achievement and these core professional values.2
AΩA expanded rapidly throughout the early twentieth century and
continues to expand in the twenty-first century. There are now 126 AΩA
chapters in medical schools, with more than 150,000 members. Member
dues provide nearly three-quarters of a million dollars to support the
following AΩA programs and awards each year: the Robert J. Glaser
Distinguished Teaching Awards, the Carolyn Kuckein Medical Student
Research Fellowships, AΩA Visiting Professorships at medical schools,
Medical Student Service Leadership Project Awards, Postgraduate Awards,
Volunteer Clinical Faculty Awards, Administrative Recognition Awards,
Student Essay Awards, the Pharos Poetry Competition, three AΩA Fellow
in Leadership Awards, and the Edward D. Harris Professionalism Award.
The society’s quarterly journal, The Pharos, publishes essays at the intersection of medicine and the humanities, as well as news about activities,
awards, and programs.
The history of medical professionalism
The first oath for medical ethics was apparently written as the Code
of Hammurabi in 2000 BC. Hippocrates and Maimonides subsequently
developed oaths codifying the practice of medicine as the sacred trust of
the physician to protect and care for the patient and a set of values for
physicians appropriate for their times.3,4 Both emphasized teaching and
learning, and the primacy of benefiting the sick according to one’s ability
and judgment while adhering to high principles and ideals. These oaths
were also a form of social contract that partially codified what patients and
society should expect from the physician.
The physician Scribonius apparently coined the word “profession” in
47 AD. He referred to the profession as a commitment to compassion,
benevolence, and clemency in the relief of suffering, and emphasized
humanitarian values.5 While patients and societies and the concept of
medical professionalism have changed over time, many of the professional
values in medicine are timeless. To paraphrase Sir William Osler: “The
practice of medicine is an art; a calling, not a business; a calling in which
your heart will be exercised equally with your head; a calling which extracts from you at every turn self-sacrifice, devotion, love and tenderness
to your fellow man.” He also wrote, “No doubt medicine is a science, but
it is a science of uncertainty and an art of probability.” 6
The science of medicine has progressed dramatically in the last hundred years. Up until the mid-1900s, doctors could diagnose some illnesses
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Preface: Medical Professionalism: Best Practices
based on the patient’s history, but they had few diagnostic tests or effective therapies. Thus one of the special roles of doctors—the art of medicine—was to relieve patients’ suffering. Scientific and technical advances
brought more effective treatments, which paradoxically led many doctors
to become less capable of compassionately caring for the suffering patient.
During the last fifty years, social changes have altered the relationship of the doctor and patient. In what is sometimes referred to as the
corporate transformation of health care, many components of medicine
have become businesses that do not put the patient first and dismiss the
special relationship between patients and their doctors. At the same time,
the profession of medicine has not responded as effectively as it should
have to protect the primacy of the care of the patient. We believe that
serving as a physician and practicing medicine must be based on core
professional beliefs and values, and that those entering and practicing our
profession must understand the values of medical professionalism and
learn and demonstrate the aptitude and commitment to behave professionally. Physicians work primarily in the service to others and our success is measured in human terms, by how well we benefit those under our
care, not necessarily in financial returns. We are evaluated and respected
because of what we actually do and how we meet our responsibilities. A
physician’s work is compassionate and includes a commitment to service,
altruism, and advocacy. Our profession of medicine is self-directed and
therefore self-regulating. The privilege of self-regulation is granted to us
by patients and society when we prove ourselves worthy of their trust by
meeting our professional responsibilities to them.
Professionalism is a required core competency for physicians. A few
decades ago, medical professionalism became an important issue. Many
researchers concluded that an integrated patient-centered approach was
needed, one that included both the science and the art of medicine. While
a disease framework is required to reach a diagnosis and select appropriate
therapy, the illness framework in which the patient’s unique and personal
experience with suffering, including individual worries, concerns, feelings,
and beliefs, is equally important. Some recognized that what Francis W.
Peabody wrote earlier was both straightforward and profoundly important: “One of the essential qualities of the clinician is interest in humanity,
for the secret of the care of the patient is in caring for the patient.” 7
Medical professionalism today
In dissecting medical professionalism to better understand the concept
and determine how to address issues of concern both to the profession and
society, most researchers have concluded that the profound and rapid advances in medical knowledge, technology, specialized skills, and expertise
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Medical Professionalism: Best Practices
have inadvertently resulted in a loss of our professional core values. Many
writers and professional organizations have proposed a renewed commitment to restore professionalism to the core of what doctors do. It seems
self-evident that we should practice medicine based on core professional
beliefs and values. In my opinion, this relates first and foremost to the
doctor-patient relationship. It starts with physicians understanding their
obligations and commitments to serve and care for people, especially the
suffering. Physicians must put patients first and subordinate their own
interests to those of others. They should also adhere to high ethical and
moral standards and a set of medical professional values. These values
start with the precept of “Do no harm.” They include a simple code of conduct that explicitly states: no lying, no stealing, no cheating, nor tolerance
for those who do. I also believe that the Golden Rule, or ethic of reciprocity, common to many cultures throughout the world—“one should treat
others as one would like others to treat oneself ”—should be the ethical
code or moral basis for how we treat each other.
Professional organizations and leaders in medicine have recently defined the fundamental principles of medical professionalism. CanMEDS
2000 stated it well: “Physicians should deliver the highest quality of care
with integrity, honesty, and compassion and should be committed to the
health and well-being of individuals and society through ethical practice,
professionally led regulation, and high personal standards of behaviour.”
The American College of Physicians and the American Board of
Internal Medicine have developed a physician charter with three fundamental principles:
1. The primacy of patient welfare or dedication to serving the interest
of the patient, and the importance of altruism and trust
2. Patient autonomy, including honesty and respect for the patients to
make decisions about their care
3. Social justice, to eliminate discrimination in health care for any
reason.8
Professional organizations have also developed a set of professional
responsibilities:
• Professional competence
• Honesty with patients
• Patient confidentiality
• Maintaining appropriate relations with patients
• Improving quality of care
• Improving access to care
• Just distribution of finite resources
• Scientific knowledge
• Maintaining trust by managing conflicts of interest
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Preface: Medical Professionalism: Best Practices
• Professional responsibility
I also believe explicit rules and values are important in medicine and
I have taken the liberty to rephrase some and add others in the following table.1 Learning requires a clear, straightforward set of expectations
combined with learning opportunities, reflection, evaluation, and feedback, and these principles may provide an important basis for physician
learning.
Professionalism in Medicine
Responsibilities to patients
The care of your patient is your first
concern
Care for patients in an ethical, responsible, reliable, and respectful manner
Do no harm
Respect patients’ dignity, privacy, and
confidentiality
No lying, stealing, or cheating, nor tolerance for those who do
Respect patients’ rights to make decisions about their care
Commit to professional competence
and lifelong learning
Communicate effectively and listen to
patients with understanding and respect for their views
Accept professional and personal responsibility for the care of patients
Be honest and trustworthy and keep
your word with patients
Use your knowledge and skills in the
best interest of the patient
Maintain appropriate relations with your
patients
Treat every patient humanely, with benevolence, compassion, empathy, and
consideration
Reflect frequently on your care of
patients, including your values and
behaviors
Social responsibilities and advocacy
Commit and advocate to improve quality of care and access to care
Respect and work with colleagues and
other health professionals to best serve
the patients’ needs
Commit and advocate for a just distribution of finite resources
Commit to maintaining trust by managing conflicts of interest
While I hope that most physicians understand, practice, and teach with
professionalism and its core values, the literature indicates that unprofessional behaviors are common. This raises the question: Can you teach
professional behaviors to students and physicians? Although medical
schools would like to select students who already have professional values
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Medical Professionalism: Best Practices
and ethics, they lack reliable tools to find those candidates and so primarily rely on academic performance for admission.
Medical schools transmit knowledge, teach skills, and try to embed
the values of the medical profession. During this curriculum and learning process do students learn to put the needs of patients first? Most of
the data indicate that students begin with a sense of altruism, values, and
open-mindedness, but they learn to focus on what is tested to pass examinations. They observe self-interest, a focus on income, and nonprofessional behaviors by their seniors in our profession and unfortunately grow
progressively more cynical and less professional, especially once they get
to clinical experiences. This is worsened by the lack of moral and professional values in the business and political components of medicine that
often disregard the patient and the patient’s needs and interests.
Although most schools have curricula related to professional values,
what students learn and retain is from what is called the “hidden curriculum”—the day-to-day experiences of students working in the clinical environment while watching, listening, and emulating resident and physician
behaviors. It is not a good story. Fortunately, some schools and teaching
hospitals have implemented effective interventions to improve medical
professionalism, and some have attempted to develop methods of evaluating aspects of professionalism. Having a few courses, however, does not
seem to make a difference in learning professionalism and professional
behaviors. The most effective programs, so far, lead by changing the institutional culture and environment to respect and reward professional
behavior, while at the same time exposing and working to change the
negative impact of the “hidden curriculum.” Many of these interventions
are top-down and bottom-up institutional changes that focus on faculty,
house staff, students, and staff members, and have shown promising reports of changes in professionalism.
We shouldn’t presume that professional core values in medicine are
intuitively apparent. I recognize there is continuing debate about the
importance and value of a physician’s “oath” or “solemn promise,” but I
believe we must have clear professional expectations that are explicit for
all physicians and a commitment from physicians to respect and uphold
a code of professional values and behaviors. In my opinion, these include
the commitment to:
• Adhere to high ethical and moral standards: do right, avoid wrong,
and do no harm.
• Subordinate your own interests to those of your patients.
• Avoid business, financial, and organizational conflicts of interest.
• Honor the social contract you have undertaken with patients and
communities.
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Preface: Medical Professionalism: Best Practices
• Understand the non-biologic determinants of poor health and the
economic, psychological, social, and cultural factors that contribute to
health and illness.
• Care for patients who are unable to pay, and advocate for the medically underserved.
• Be accountable, both ethically and financially.
• Be thoughtful, compassionate, and collegial.
• Continue to learn, increase your competence, and strive for
excellence.
• Work to advance the field of medicine, and share knowledge for the
benefit of others.
• Reflect dispassionately on your own actions, behaviors, and decisions
to improve your knowledge, skills, judgment, decision-making, accountability, and professionalism.9
The chapters in this monograph, Medical Professionalism: Best
Practices, present their authors’ experiences both in building cultures of
medical professionalism and dealing with lapses in professionalism. We
hope that it will support medical schools, professional organizations,
practitioners, and all involved in health care in their very important work
on professionalism in medicine.
Bibliography and references
1. Papadakis MA, Paauw DS, Hafferty FW, et al. Perspective: The education
community must develop best practices informed by evidence-based research to
remediate lapses of professionalism. Acad Med 2012; 87: 1694–98.
2. Byyny RL. AΩA and professionalism in medicine. The Pharos Summer 2011;
74: 1–3.
3. Edelstein L. The Hippocratic Oath: Text, Translation and Interpretation.
Baltimore (MD): Johns Hopkins University Press; 1943.
4. Tan SY, Yeow ME. Moses Maimonides (1135–1204): Rabbi, philosopher,
physician. Singapore Med J 2002; 43: 551–53.
5. Hamilton JS. Scribonius Largus on the medical profession. Bull Hist Med
1986; 60:209–16.
6. Bliss M. William Osler: A Life in Medicine. New York: Oxford University
Press; 2007.
7. Oglesby P. The Caring Physician: The Life of Dr. Francis W. Peabody.
Cambridge (MA): Harvard University Press; 1991.
8. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM
Foundation, American College of Physicians-American Society of Internal
Medicine; European Federation of Internal Medicine. Medical professionalism
in the new millennium: a physician charter. Ann Intern Med 2002; 136: 243–46.
9. Byyny RL. AΩA and professionalism in medicine—continued. The Pharos
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Introduction
1
Chapter 1
Introduction
Maxine A. Papadakis, MD
T
he longstanding commitment to enhancing professionalism by the
Alpha Omega Alpha Honor Medical Society (AΩA) and the Josiah
Macy Jr. Foundation is remarkable. Their recent commitment to
highlighting the need to focus on remediation strategies to address lapses
in professional behavior is farsighted and welcome in the educational
community. Many tools have been developed to assess professional behavior, but as was pointed out in the 2011 AΩA Think Tank on lapses in
professionalism,1 assessment has limited value unless it leads to improvement. What is known about remediation for lapses of professional behavior in medical students? Hauer et al. reviewed the published outcome data
on remediation efforts in a 2009 paper in Academic Medicine.2 She and
her colleagues found that many of the published studies lacked the robust
scientific outcomes that learners and medical educators deserve. The
conclusion from the Hauer paper was that there was an urgent need from
multi-institutional outcomes-based research on strategies for remediation.
This monograph addresses professional behaviors and organizational
structures as they impact professionalism. Here we present a framework
for the papers that follow. The first group of papers addresses systems
and organizational structures that influence the professionalism of every
member of a community, but lapses by medical students get particular attention. In order to do so, studies about lapses of the professional behavior
of faculty and practicing physicians are extrapolated to lapses in medical
students. The next set of papers addresses interventions directed at an
individual learner.
Definitions of professionalism based on lists of measureable professional behaviors are functional for teaching, assessment, and certification.
In several ways, though, there is a risk that the list-based definitions will
obscure the foundational purpose of professionalism, a view supported by
many broad definitions of professionalism, including a recent one written
for the American Board of Medical Specialties.3 The broader understanding of professionalism extends beyond definitions and behaviors. Defining
professionalism as a list of personal attributes suggests that the operationalization of professionalism is only at the level of the individual, which may
deflect attention from the essential organizational and systems structures
that underline professionalism. Professionalism transcends the list of
desirable values and behaviors; it is the belief system, the reason for creating the lists and acting in accordance with them.3 Lesser and colleagues
have pointed out the fallacy in the belief that medical educators can come
3
Medical Professionalism: Best Practices
up with an exhaustive list of the professional behaviors that learners will
need across the continuum of their education.4 Rather, these authors offer
a broader perspective of professionalism by calling for the need to educate learners to recognize and navigate conflicts in professionalism. This
broader perspective of professionalism will help learners when we cannot
articulate what those behaviors are.
While respecting the broader perspective that professionalism is a belief system that transcends behaviors, there remains a compelling need for
the delineation of best practices to address lapses in professional behavior
while we await evidence from interventional studies. “Best practices” at
this time means “best consensus opinions” based on the experience and
expertise of medical education faculty, particularly those from the student
affairs arena. Consensus expert opinion is available and does not need to
wait for the truly “best practices” based on evidence with documented
outcomes. Best consensus opinions could be gathered to answer questions such as what should be the academic consequences for a third-year
medical student who at the end of a required clerkship demonstrates
mastery in fund of knowledge and clinical problem-solving skills, but not
professionalism. Since the competency of professionalism is one of the
six core Accredited Council of Medical Education (ACME) competencies,
should the medical student repeat the clerkship? If the medical student is
to repeat the clerkship, should there be an intervention to remediate the
student’s deficiency in the competency of professionalism? Alternatively,
since the medical student is being given another chance to learn skills in
professionalism by observing and modeling behaviors when repeating the
clerkship, is the experience gained from repeating the clerkship adequate
remediation? If the student is not to repeat the clerkship (the assumption,
therefore, is that the student passed the rotation), what remediation plans
should be put in place to help the student? What should be the outcome
measures?
Medical schools can use such best practices to fulfill their responsibility to graduate physicians who leave medical school with the school’s
confidence that the physician will act professionally. Best practices will
reflect a consensus of the education community about what is the right
thing to do and how much is reasonable for schools to do to fulfill their
obligation to create the educational environment in which learners excel.
Best practices can help clarify the boundary between the school’s obligations and the individual learner’s obligation to meet the competency of
professionalism. Best practices can help answer the question of whether a
medical school has done enough to help a learner who is having lapses in
professional behavior. Does the medical school have the right resources
and the right systems in place to help the learner? Consensus about best
4
1. Introduction
practices will help medical schools answer the tough question of whether
a learner should be allowed to continue in medical school or when it is
time for the learner to leave because the educational community has come
together and defined what are reasonable resources to help the learner.
The literature provides information about which professional behaviors
are core and should be on lists of measurable professional behaviors for
teaching, assessment, and certification. The choice to include these behaviors on lists, however, is based on the premise that these behaviors can be
accurately and validly assessed. How do American medical schools assess
professionalism? From a survey published in 2011,5 professionalism is assessed by several modalities, but what links them together is direct observation. Direct observation is critical for the assessment of professionalism;
it is not as critical for the assessment of fund of knowledge, for which
more quantitative, multiple choice, and even essay testing formats are
effective. A further discussion of assessment instruments is beyond the
scope of this paper, but several tools to assess professional behavior have
been developed and studied, including the Assessment of Professional
Behaviors Program by the National Board of Medical Examiners (https://
www.mededportal.org/publication/9902), the Professionalism Minievaluation Exercise,6 the Conscientiousness Index,7 and the physicianship
forms from UCSF.8,9
The behaviors that comprise professionalism can be organized around
four areas, which are: (1) responsibility; (2) capacity for self-improvement;
(3) relationship with patients; and (4) relationship with the health care
team and the environment, including systems and organizations. A 2005
study from UCSF, Jefferson Medical College, and University of Michigan
Medical School linked unprofessional behavior during medical school
with subsequent disciplinary action by state medical boards.9 The presence of unprofessional behavior had the highest attributable risk (twentysix percent) for subsequent disciplinary action of the measured predictor
variables. That study described associations that were epidemiologic; the
associations could not be extrapolated to an individual learner because of
the limitations in sensitivity, specificity, and predictive value of the variables. The study did provide insights, however, about particular behaviors
that were associated with subsequent disciplinary actions. Medical students who displayed a pattern of irresponsibility while in medical school
were nearly nine times more likely to be subsequently disciplined by a
medical licensing board; board actions could occur even decades later.
Finding an odds ratio as high as nine in that retrospective study, while
taking into account the limitations of the research design, is likely a conservative estimate of the risk and the importance of this behavior. Nine
5
Medical Professionalism: Best Practices
times a rare outcome, nonetheless, remains rare since less than a percent
or so of physicians are disciplined by state licensing boards.
The behavior of irresponsibility includes unreliable attendance at clinic,
problematic notification about missed attendance, not following up on activities related to patient care, being late or absent for assigned activities,
and being unreliable. An example of an irresponsible student is one who
repeatedly shows up late for didactic and small group sessions, as well as
the start of a call day. The student has an imprecise excuse for being late;
his peers are aware of the tardiness. Such learners can be taught that being
responsible is an expectation of their professional development and that
being irresponsible has risk for subsequent disciplinary actions. Behaviors
in the domain of responsibility are measurable. What is unknown is the
outcome of learners who display a pattern of irresponsibility and then
receive remediation. Have these learners learned to stay under the radar
screen or have they accepted the belief system of professionalism, with the
ability to recognize and navigate challenges in professionalism?
The second behavior is diminished capacity for self-improvement, such
as failure to accept or incorporate constructive criticism. This behavior
includes interactions described as brusque, hostile, argumentative, or
negative. A poor attitude, arrogance, over-confidence, or overly sensitive
are additional descriptors. An example of such a student is one who is perceived as being demanding and insensitive to the needs of other students;
the student often interrupts fellow students during their presentations.
Nurses note that the student is arrogant. The staff notes that the student
complains about the clinic schedule and requests changes to assignments.
The student is vocal about the shortcomings of the school’s evaluation
system.
The third behavior centers around impaired relationship with patients,
failure to establish rapport, and insensitivity to patients’ needs. The fourth
behavior concerns relationship with the health care environment, such
as not being respectful to members of the health care team, and creating
a hostile educational environment. The literature is replete with studies showing the importance of the medical team’s dynamics for patient
safety. The behaviors of testing irregularity and falsification of patient data
are included here. Likely there is uniform consensus that falsification of
patient data is unacceptable. What is unknown, however, is whether all
testing irregularities should be of similar concern. If a student seated near
another student copies an answer from a multiple choice test, is that as
worrisome as someone who cheats on a licensing examination?
In addition to the four behaviors, one needs to pay attention to the pattern of lapses of professionalism within each behavior. An isolated lapse
can be just that, isolated; the individual may be displaying poor coping
6
1. Introduction
skill for a compelling life event such as a flare in a health problem or a
divorce. A pattern of lapses likely foreshadows later problems with disciplinary actions.9
Another consideration is when a lapse of professional behavior occurs.
Are the implications the same for professionalism when a second-year
medical student creates a hostile learning environment in a small group
setting as when an attending physician creates a hostile learning environment for residents? Would the attending physician not have created a
hostile learning environment if the operating room ran more efficiently?
What are the accountability dynamics between inefficient systems and the
individual physician?
The severity of the lapses is also important. Learners must be given the
opportunity and skills to develop professionally, which include navigating challenges to professionalism and maturing over time, just as learners gain and improve their skills in fund of knowledge and clinical care.
Minor lapses in professional behavior should be considered part of the
developmental spectrum as the learner develops professional identify.
Consideration about lapses in professional behavior must also take into
account whether the learner is on a trajectory of improvement. Another
context for lapses in professionalism may be when there is a change in the
environment. Every time a student rotates onto a new clerkship, she becomes anxious, argumentative, and hostile. As she feels safer, her behavior
improves. But the pattern does not improve as she repeats the cycle every
time she rotates into a new setting.
The papers that follow explore professionalism from the lens of systems, the learner, and the patient.
References
1. Papadakis MA, Paauw DS, Hafferty FW, et al. Perspective: The education
community must develop best practices informed by evidence-based research to
remediate lapses of professionalism. Acad Med 2012; 87: 1694–98.
2. Hauer KE, Ciccone A, Henzel TR, 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: 1822–32.
3. Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. More than a
list of values and desired behaviors: A foundational understanding of medical
professionalism. Acad Med 2014; 89: 712–14.
4. Lesser CS, Lucey CR, Egener B, et al. A behavioral and systems view of
professionalism. JAMA 2010; 304: 2732–37.
5. Barzansky B, Etzel SI. Medical schools in the United States, 2011–2012.
JAMA 2012; 308: 2257–63.
6. Cruess R, McIlroy JH, Cruess S, et al. The Professionalism Mini-evaluation
7
Medical Professionalism: Best Practices
Exercise: A preliminary investigation. Acad Med 2006; 81 (10 Suppl): S74–78.
7. McLachlan JC, Finn G, Macnaughton J. The conscientiousness index: A
novel tool to explore students’ professionalism. Acad Med 2009; 84: 559–65.
8. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional
behavior in medical school is associated with subsequent disciplinary action by a
state medical board. Acad Med 2004; 79: 244–49.
9. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by
medical boards and prior behavior in medical school. N Engl J Med 2005; 353:
2673–82.
8
Chapter 2
The Problem with Professionalism
Catherine R. Lucey, MD
A
lthough we may disagree with the size or the cause of the problem,
many educators, practitioners, leaders, and unfortunately patients
would agree that the medical profession currently has a problem
with professionalism. All too often we have seen headline stories about
physicians engaged in behavior that is not only unprofessional but criminal: murder, pedophilia, and financial fraud. While these are horrific, the
profession generally has no difficulty in responding quickly to sanction or
remove a physician who has engaged in these types of behaviors.
Unfortunately, these unusual circumstances represent the tip of the
iceberg of professionalism problems. Our commitment to professionalism
as a community is more often damaged by behaviors that can be seen daily
in every care arena. Examples include overtly disruptive behaviors such as
abuse of power manifested by failure to comply with evidence-based safety
practices, and intimidation of others by yelling, profanity, and threats of
physical violence. Also common are covertly disruptive behaviors such
as failing to answer pages or complete essential paperwork on time. Even
more common are daily incivilities: sarcastic comments on rounds about
patients, specialty bashing, and snarky comments about learners. Perhaps
most threatening to a culture of professionalism is our collective tolerance to these behaviors: many articles document the failure of physicians
to step in and correct unprofessional behavior despite a commitment to
professional self-regulation.
The causes of our problem with professionalism are complex
and controversial
Many have hypothesized that the problem with professionalism is a
result of changes in the generational commitment to professionalism as a
result of the ACGME-mandated work hours restrictions, enacted across
the country at the beginning of the twenty-first century. But in reality,
concerns about the state of medical professionalism, as reflected in the
exponential growth of peer-reviewed literature on this topic, began in
the early 1980s.1 This occurred in parallel with a number of significant
events that disrupted the way that physicians related to each other, their
patients, the health care systems in which they worked, and the learners
they taught.
In the mid 1980s, the shift from pure fee-for-service reimbursement to
a strategy based on diagnosis-related groups (DRG) dramatically shortened the number of days that patients spent in the hospital and increased
9
Medical Professionalism: Best Practices
the pressure on physicians to rapidly admit and discharge patients. The
tragic death of Libby Zion ushered in an era in which the length of time
residents spent in the hospital was dramatically curtailed. In the mid
1990s, fraudulent billing by some physicians led to the implementation
of Physicians at Teaching Hospitals (PATH) regulations that changed
the work flow of teaching hospital rounds. Teams could no longer share
the work of documentation, and time for teaching decreased. In the late
1990s, the Balanced Budget Act plunged many academic medical centers
into the red overnight and an era of high-volume-throughput medicine
began. This further shortened already abbreviated hospital stays, making
the development of relationships between residents and their hospitalized patients more difficult. The Institute of Medicine reports on medical
errors in 1999 and quality in 2002 publicized the difficulty of providing
consistently high quality safe patient care. The move to shorten residency
work hours across the country and in all disciplines clearly has impacted
the ways in which we work and how learners view their roles, but this was
only the most recent of a long line of challenges to professionalism.
Different types of problems require different types of
solutions
A problem exists when there is a gap between the realities we experience and the ideals to which we aspire. In the world of problem solving,
there are two types of problems: technical and complex adaptive problems.2,3 Technical problems are easy to recognize and define. All who experience them agree on the nature of the problem and the characteristics
of the desired state. Technical problems either exist in isolation or are
relatively unaffected by changes in the environment. Solutions to technical problems are well established, can be found in a book on a shelf or an
article on the Internet, and can be outsourced. Once fixed, a technical
problem tends to stay fixed. Classic technical problems are fixing a flat
tire or a dripping water faucet.
In contrast, complex adaptive problems are characterized by controversy and volatility. They arise insidiously out of seemingly stable environments. People will disagree about the extent, nature, or cause of the
complex adaptive problem and often they will disagree on the characteristics of the ideal state. Complex adaptive problems are highly influenced
by the environments in which they exist and thus are always changing.
The controversial and complex nature of these problems means that no
“off-the-shelf ” solution is possible: the people who experience the problem must work and learn together to address the problem using multiple
lenses. Because they are highly susceptible to environmental influences,
complex adaptive problems are almost never permanently solved; they are
10
2. The Problem with Professionalism
merely managed as well as they can be within their existing contexts. They
require continuous tending. Classic complex problems include poverty,
drug addiction, underperforming schools, and teenage pregnancy.
The clues to the nature of the problem of professionalism are evident in
the published literature and in presentations at national meetings. Articles
have carefully explored beliefs about professionalism, searched for causes
of deteriorating culture of professionalism, and called for a renewed commitment to professionalism. Debates are heard throughout academic
medical center: Is professionalism worse than it has been in the past? Is
it a pervasive problem or one that is isolated to a few bad actors? Is this
a problem with the new generation of physicians or the most seasoned
generations? We might similarly disagree on the future ideal: is altruism
an outdated idea in the era of regulated work hours?
Sustaining professionalism is a complex adaptive problem
It is clear from these questions that the problem of sustaining professionalism meets all the criteria of a complex adaptive problem. Despite
this, the medical profession has approached the problem as a technical
one: seeking the single true cause and best solution even though the
complexity of the problem mandates a different approach. The reliance
on technical approaches stems from a commonly held assumption that
professionalism is a dichotomous virtue—either present or absent in any
given individual. The technical approach that follows this perspective is
illustrated as a series of sequenced strategies, largely concentrated in the
medical education environment. The strategies: recruit the right people,
teach them the rules of professionalism, expose them to role models who
skillfully apply those rules in the clinical environment, and then reward
them with an MD degree and release them into the public. During this
process, assess them carefully and be ready to impose sanctions or remove
them from the profession if they commit a professionalism lapse. There is
some data to suggest that the medical education environment does have
a role as a gatekeeper for professionalism. In a seminal article in the New
England Journal of Medicine, Papadakis and colleagues documented that
physicians who were sanctioned by medical boards for unprofessional
behavior were more likely to have been the recipients of more than one
professionalism complaint during their medical school careers.4
Our current solutions are insufficient or ineffective
But if one reviews the literature that evaluates the success of interventions aligned with this approach, the results are disappointing. The
problem with optimizing recruitment as a strategy for enhancing professionalism should be evident. Little data exists at the time of admission to
11
Medical Professionalism: Best Practices
medical school that could or should predict an individual’s ability to live
the values of professionalism in the clinical environment.5,6 Scores on
standardized exams, whether they test knowledge of the life and physical
sciences or the social and behavioral sciences, may indicate whether the
individual has mastered knowledge that would help an individual understand a particular challenge, but not whether he or she then will act in a
desired fashion when confronted with that challenge. Interview questions
and essays may uncover whether a potential student can articulate the values of professionalism and identify those who aspire to live those values.
However, very few applicants to medical school have had the opportunity
to test their ability to live those values in the stressful environment of
health care.
The idea that professionalism can be taught as a series of rules has also
proved to be problematic. On the surface, it is attractive to translate the
abstract constructs of professionalism (altruism, respect, confidentiality,
integrity, professional self regulation) into desired rules and behaviors.
Campbell’s survey of over 1,000 internists demonstrated that while the
vast majority of physicians surveyed agreed with the tenets of professionalism, many were aware of instances in which they themselves or their
colleagues did not live up to those values.7 Huddle noted that this disconnect between intent and behavior was such a common situation that the
ancient Greeks had a specific word for it: akrasia, meaning that the spirit
was willing but the flesh was weak.8
The story becomes more complex still when we rely on the teaching of
rules to educate and assess professionalism. In a series of elegant experiments, Ginsberg and colleagues concluded that the rules of professionalism are not static and universal, but highly contextual.9 Additionally,
faculty physicians provided with several exemplar cases of professionalism challenges were both externally and internally inconsistent in their
decisions about what was the professional thing to do and why.10 In one
scenario, faculty were asked to identify the right response of a medical
student who, after being instructed by his faculty physician not to inform a patient of a new diagnosis, is specifically asked by the patient to
disclose the diagnosis. Some faculty stated emphatically that the student
should reveal the diagnosis because the student should never lie; others
said that the student should lie to the patient under these circumstances.
Furthermore, those physicians who maintained that students should
never lie to a patient subsequently suggested that there were cases in
which the right response might be to lie. This work suggests that professional responses to complex situations are nuanced and not reducible to
a core set of rules or commandments. In light of the variability of “correct responses” by different faculty, it also raises the concerns about the
12
2. The Problem with Professionalism
validity and reliability of assessing professionalism based on the response
to isolated incidents.
Given the poor performance of rules as a mechanism for teaching, one
might conclude that professionalism education must rely upon assigning
students to role models who have successfully learned to deal with the
ambiguity of professionalism challenges and who can articulate why a
specific response is appropriate in a given situation. Unfortunately, the
literature on the impact of role models in teaching professionalism is also
disappointing. Hafferty coined the term “the hidden curriculum,” describing the frequent disconnect between the lessons that are explicitly taught
in the classroom and those that are modeled, learned, and rewarded in
the clinical environment.11 The inability of all role models, particularly
those that appear to be otherwise professionally successful, to apply the
lofty professionalism values in the clinical arena contributes to cynicism
in trainees that may progress during training.12
If recruitment strategies are unreliable, rules are ambiguous and contextual, and role modeling by professionals is inconsistent, then perhaps
the solution to the problem of professionalism must default to aggressive
assessment and removal of those who exhibit unprofessional behaviors.
Unfortunately, this also is an incomplete solution to the problem. As noted
previously, faculty disagree about what the “right” behavior is in given
professionalism challenges. This means that whether a behavior exhibited
by a learner is deemed unprofessional depends on who is doing the observation: hardly a strong basis on which to take action. Furthermore, those
with the power or authority to take corrective action may not be present
when learners are engaging in acts of unprofessional behavior. Finally, literature exists that documents that faculty who do witness unprofessional
behavior may be reluctant to address that behavior in any way.13 Mizrahi
was particularly dismayed by what he described as a set of maladaptive
behaviors that physicians engaged in rather than confront a colleague
who had made an error. He described these as denial (“It wasn’t unprofessional”), discounting (“It was unprofessional but it was warranted”), or
distancing (“It was unprofessional but let’s just move on”).14 Faculty or
colleagues may also fail to correct a professionalism lapse because they
lack confidence in their ability to intervene successfully or they may be
concerned that a report to a higher authority will result in sanctions that
are disproportionate to the episode that they witnessed.
Evaluating professionalism lapses as a form of medical error
When problems cannot be solved with conventional approaches, new
learning is required. In considering common professionalism lapses, we
recognized that there are similarities between professionalism lapses and
13
Medical Professionalism: Best Practices
medical errors. Like medical errors, professionalism lapses are more common than we might think. They occur in predictable circumstances: when
individuals are stressed, the situations are highly charged, and controversy
is present. Professionalism lapses range in severity from largely invisible
(for example, the faculty member who claims CME credit for a lecture
he didn’t attend) to potentially fatal (the resident who leaves the hospital
without checking on a post-procedure chest X-ray). As is the case with
medical errors, those whom we otherwise consider to be good physicians
commit occasional professionalism lapses; thus professionalism must
result from a temporary mismatch between the individual’s knowledge,
judgment, or skill and the complexity of the situation in which he finds
himself. Finally, the systems in which we care for patients and educate
learners may either help us sustain our professional values or set us up
for failure.
If we consider professionalism lapses to be either analogous to or a form
of medical error, we can apply the tools that have been useful in managing
medical error to the problem of professionalism lapses. Establishing a “just
environment,” in which people are encouraged to report professionalism
challenges, lapses, and near misses can help us understand the spectrum
of professionalism problems. Root-cause analysis may enable us to fully
characterize the many causes of professionalism lapses. In combination,
these tools can guide us in devising strategies to help all professionals and
learners prevent or address professionalism lapses. Finally, the concept of
active lapses (those caused by a physician) and latent lapses (those caused
when the system fails to protect the vulnerable patient from the fallible
physician) adds additional intervention points for leaders to consider.
Analyzing lapses: Conflicts abound and systems may set
people up to fail
Analyzing articles written about professionalism challenges (difficult
situations) and lapses (challenges that were not managed well) from the
perspective of students, residents, faculty, practicing physicians, and
scholars give insights into the root cause of professionalism lapses, as does
our own experience in working with learners and faculty who have lapsed.
Professionalism challenges tend to be crowded: they often require the clinician to simultaneously manage the needs and expectations of multiple
people (the patient, peers, learners, faculty, nurses, administrators and
others). In managing challenges, several conflicts are present (Table 1).
Ginsberg and colleagues have described the challenge of values conflicts:
when adhering to one professionalism value means subjugating another
professionalism value. In addition to values conflicts, there may be patient
conflicts: when attempting to be professional with one patient puts you at
14
2. The Problem with Professionalism
odds with another patient.15,16 Finally, the most common cause of lapses
appears to be Maslow conflicts, when adhering to a professionalism value
requires that an individual subjugate his fundamental physiologic, safety,
belonging, or esteem needs.17 Maslow theorized that human beings, when
faced with decisions on how to act, will predictably choose the decision
that meets their deficit needs for food, water, sleep, safety, and belonging
before acting selflessly.
Table 1. Conflicts Are a Frequent Cause of Professionalism Challenges
Values
conflict
An intern is expected to adhere to the professionalism value of excellence by leaving after she has been on a shift that exceeds work hours
limits and to demonstrate altruism for her patient by staying to conduct a family meeting after that shift ends.
Patient
conflict
A faculty member demonstrates compassion for a patient who has just
received bad news by extending the length of that patient’s appointment; the subsequent patient views him as unprofessional for keeping
him waiting.
A physician wants to maintain confidentiality about his patient’s communicable disease, but doing so puts other of his patients at risk.
A resident is trying to actively manage a dying cancer patient’s pain
and therefore must defer seeing another patient whose nonmalignant
chronic pain syndrome is not well managed.
Maslow
conflict
A medical student is assigned to care for an angry patient in the middle
of the night; he hasn’t eaten for fifteen hours and is very anxious about
performing well.
Systems
conflict
A resident is instructed to see all patients who are to be discharged
now so that they can be out of the hospital by 11 AM. She is repeatedly
called to come to the emergency room to evaluate a new admission
because the emergency room resident has been told to clear out the
ED before 9 AM.
The concept of latent errors, or decisions made about how health care
systems are run, also has relevance to the topic of professionalism lapses.
Staffing and workload issues may cause significant stress and distraction for professionals, leading to many conflicts as they attempt to serve
multiple patients simultaneously. Inconsistent, ambiguous, or conflicting
expectations from employers or accreditors can also cause lapses, as is
the case when residents are told to always put their patients’ needs above
their own, but are then instructed that they must drop everything and
leave when they have reached the maximum number of hours on duty.
Institutional policy decisions about how clinicians are rewarded may
15
Medical Professionalism: Best Practices
prioritize high-volume throughput of patients over high-quality patient
care and teaching. Legal policies and indemnity strategies may make it
difficult for physicians and others to apologize when an error has been
made. Finally, national health care decisions that leave millions uninsured
or that prohibit conversations like end-of-life care may also set physicians
and others up to fail.
A new perspective
With this analysis in mind, we propose a new perspective: we expect
that all professionals will be deeply committed to living the values of
professionalism but at times will be challenged by circumstances that
are stressful and trying. To ensure that our profession meets our obligations to society, we must teach all professionals to anticipate and skillfully
manage even the most challenging of professionalism circumstances. If
successful, we will cultivate a generation of fully formed professionals
who, as articulated by Leach, recognize that “Professionalism means going beyond the amateur in participating in the relationships . . . The fully
formed professional is habitually faithful to professional values in highly
complex situations.” 18
Managing a professionalism challenge requires judgment
and skill
Any time you routinely expect human beings to behave in a way that
is counter to human instinct or human incentive, you are dealing with a
challenge of acquired competency. Thus, preparing people to be habitually faithful to professional values in these complex situations means that
we must view professionalism not as a character trait but as a complex,
multidimensional competency. Like other complex competencies, the
competency of professionalism must follow a developmental curve19 in
which intent to comply and live values of professionalism is the entry
into the profession, but mastering the skills and judgment to live professionalism despite hostile environments requires practice, reflection, and
coaching. Lapses are likely to occur when the complexity of the situation
exceeds the developmental level of the professional in question. Thus, an
entering student can and should be able to articulate the values of professionalism in a context-free environment, but may stumble in solving
a challenge that requires her to prioritize one value over another or one
patient over another. A resident judged to be competent in professionalism may be able to successfully navigate a professionalism challenge
between patients, but may be less adept when he is asked to do so after
a long stretch of night float shifts. At the other end of the developmental
spectrum, an established physician must be able to successfully navigate
16
2. The Problem with Professionalism
stressful situations as well as conflicts between patients and values despite
having unmet deficit needs.
Teaching the seven skills of professionalism resiliency
Dealing with professionalism as a pedagogical challenge provides new
opportunities. First, we can expand our teaching about professionalism
beyond descriptions of behavior we expect and into skills that foster resiliency. None of these skills are routinely taught or assessed in our conventional courses on doctor-patient relationships but should be added to all
medical curricula. They focus on skills to manage self as well as skills to
interact effectively with all in the health care environment. Table 2 summarizes the seven skill sets needed for professionalism resiliency.
Table 2. Seven Skills for Professional Resilience
1.
Situational analysis
Recognize when the situation involves conflicts
among values or patients and what those conflicts entail.
2.
Self awareness and self
control
Recognize personal triggers and signs of personal
stress/anxiety; learn to assess for these before
high-stakes or stressful encounters; develop
strategies to optimize personal well-being in the
moment and over the long term.
3.
Alternate strategy
development
Devise strategies to obtain assistance quickly.
4.
Advanced communication: diplomacy,
de-escalation, conflict
management
Learn techniques to interact with patients and
others within the health care environment.
5.
Managing professional
boundaries
Recognize the risks of boundary violations and
develop skills to avoid or recover from boundary
crossings.
6.
Peer coaching and
intervention
Develop skills to recognize when colleagues appear to be at risk of a professionalism lapse and
to intervene before the lapse occurs; learn how
to counsel someone after the lapse has occurred.
7.
Effective apologies
Learn to apply the elements of a successful apology when a lapse has injured a relationship.
The first of these skills is situational analysis: helping learners and physicians to recognize when the situation in front of them is complex and
may include values or patient conflicts. They must recognize the need to
17
Medical Professionalism: Best Practices
slow down and make an explicit decision about what to do, rather than
simply responding with human instinct. There is a growing literature on
the importance of switching between generally appropriate fast thinking
and more methodical slow thinking that provides relevant models for this
type of work.20–22
The second set of skills that must be inculcated comes from the emotional intelligence literature: the skills of self awareness and self control.
Teaching residents and learners that they should pause and take stock of
their own emotions before they deal with a predictably challenging situation can be life changing.
The third set of skills includes the ability to generate alternate strategies
for action that go beyond the first instinctive response. Formal training in
diplomacy, conflict de-escalation, crisis communication, and negotiation
can be useful in helping professionals defuse tense situations, whether
they occur between professionals or with patients. These are different
skills than the usual relationship building or transactional information
gathering skills that are included in doctor-patient relationship courses.
Education about and skill in identifying and maintaining appropriate
professional boundaries is currently a focus in the training of psychiatry
residents, but all professionals should be skilled in this competency.
A core responsibility and value of professionalism is professional self
regulation: the responsibility of the profession to police itself. Physicians
must be taught how to intervene when a lapse seems imminent and how
to coach peers who have committed a lapse.
Finally, recognizing that lapses will occur even in the best of circumstances, we must teach our professionals how to express a genuine and
effective apology if their behavior or words have injured another.
Shaping the system to support professionalism
As leaders in the health care environment, we must shape our care
delivery systems to support a culture of professionalism. All, not merely
those who work in education, must recognize the existence and the danger
of the “hidden curriculum.” We must work to develop a culture in which
all welcome an intervention by a colleague if a professionalism lapse is
imminent or has occurred. We should champion positive examples of
professionalism so that the stories that circulate among our learners and
our peers are those describing us when we are at our best, not gossiping
about us when we are at our worst.23 We must facilitate interprofessional
teamwork, incorporating shared values of professionalism and welcoming
support and coaching from all in the health professions. We should take
steps to remove unnecessary stressors by ensuring that institutional policies and procedures reinforce rather than undermine desirable behavior.
18
2. The Problem with Professionalism
We must devise service recovery systems for all who have been harmed by
a professionalism lapse.24 All organizations should support reflection and
renewal through both environmental and event planning. Quiet rooms for
professionals to go to gather their thoughts, calm down, and recommit to
professionalism values should be available on all patient care units. Events
that celebrate and create community are essential to establishing the positive culture of professionalism.
Recalibrating our approach to professionalism lapses in
learners
As educators, we need to engage in continuous formative evaluation
of professionalism. We should test professionalism skills in our learners
in varied situations, both real and simulated. We should use root-cause
analysis to identify and debrief professionalism lapses and to teach our
learners to do the same. We need to use a developmental lens when assessing professionalism lapses in trainees so that the intervention is proportionate to the severity, and tailored to address the root cause of the
lapse in the learner. Disciplinary action should be reserved for individuals
who refuse to engage in honest self-reflection, are unwilling to accept responsibility for their behavior and other’s perceptions of their behaviors,
are resistant to coaching and counseling, or who demonstrate recidivist
behavior despite educational interventions.
Encouraging continuing professionalism education
Finally, as in ethics, advances in biomedical science, care delivery, and
health care economics will bring new challenges to professionalism.
Table 3. Biomedical and Social Advances that
May Present Professionalism Challenges
Risk sharing in the
Affordable Care Act
May create an appearance of conflict of interest if physicians are incentivized to limit care because of costs to
the system.
Returning pleiotropic results from genetic testing
to patients
Physicians who disclose all possible implications of
genetic testing may cause harm to patients; those who
select which information to share may be charged with
paternalism or lying.
Cord blood testing for
perinatal diagnosis of
genetic risk for adult
disease
Physicians disclosing risk to parents about conditions
that will not appear before adulthood may be violating
patient confidentiality.
19
Medical Professionalism: Best Practices
Table 3 summarizes recent advances that may have implications for
appropriate professional behavior. While we have accepted the need to
continuously update our biomedical knowledge, we have treated professionalism as a label that is earned once and assumed to be stable throughout the course of a career. It is time for professionalism as a renewable
competency to also be reflected in continuing medical education courses.
In summary
If we wish to fulfill our commitment to society to educate and sustain
health care professionals who are committed to and capable of living the
values of professionalism, we can no longer afford to assume that professionalism is a character trait that is established at the time of entry into
medical school. Instead, we must embrace the concept of professionalism
as a complex competency. We must seek ways to prepare our physicians
to exercise, adapt, and improve the judgment and skills needed to remain
professional despite the dynamic and stressful environment in which
health care is delivered. As a community, we must also take responsibility
for shaping the systems in which we practice so that they support our core
values. The work is hard, but the reward will be great if we as a profession
embrace this challenge.
References
1. Smith LG. Medical professionalism and the generation gap. Am J Med
2005; 118: 439–42.
2. Heifetz R, Linsky M. Leadership on the Line: Staying Alive through the
Dangers of Leading. Boston (MA): Harvard Business Review; 2002.
3. Lucey C, Souba WC. Perspective: The problem with the problem of
professionalism. Acad Med 2010; 85: 1018–24.
4. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional
behavior in medical school is associated with subsequent disciplinary action by a
state medical board. Acad Med 2004; 79: 244–49.
5. Stern DT, Frohna AZ, Gruppen LD. The prediction of professional
behaviour. Med Educ 2005; 39: 75–82.
6. Albanese MA, Snow MH, Skochelak SE, et al. Assessing personal qualities
in medical school admissions. Acad Med 2003; 78: 313–21.
7. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine:
Results of a national survey of physicians. Ann Intern Med 2007; 147: 795–802.
8. Huddle TS, Accreditation Council for Graduate Medical Education
(ACGME). Viewpoint: Teaching professionalism: Is medical morality a
competency? Acad Med. 2005; 80: 885–91.
9. Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution:
A newconceptual framework for evaluating professionalism. Acad Med 2000; 75
20
2. The Problem with Professionalism
(10 Suppl): S6 –S11.
10. Ginsburg S, Regehr G, Lingard L. Basing the evaluation of professionalism
on observable behaviors: A cautionary tale. Acad Med 2004; 79 (10 Suppl): S1–4.
11. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the
structure of medical education. Acad Med 1994; 69: 861–71.
12. Testerman JK. The natural history of cynicism in physicians. Acad Med
1996; 71 (10 Suppl): S43–45.
13. Burack JH, Irby DM, Carline JD, Root RK, Larson EB. Teaching compassion
and respect. Attending physicians’ responses to problematic behaviors. J Gen
Intern Med 1999; 14: 49–55.
14. Mizrahi T. Managing medical mistakes: Ideology, insularity and
accountability among internists-in-training. Soc Sci Med 1984; 19: 135–46.
15. Ginsburg S, Regehr G, Stern D, Lingard L. The anatomy of the professional
lapse: Bridging the gap between traditional frameworks and students’ perceptions.
Acad Med 2002; 77: 516–22.
16. Ginsburg S, Regehr G, Lingard L. The disavowed curriculum:
Understanding student’s reasoning in professionally challenging situations. J Gen
Intern Med 2003; 18: 1015–22.
17. Bryan CS. Medical professionalism and Maslow’s needs hierarchy. Pharos
Alpha Omega Alpha Honor Medical Soc 2005 Spring; 68: 4–10.
18. Leach DC. Professionalism: The formation of physicians. Am J Bioeth 2004
Spring; 4: 11–12.
19. Dreyfus SE, Dreyfus HL. A Five-Stage Model of the Mental Activities
Involved in Directed Skill Acquisition. Available at: http://stinet.dtic.mil/cgi-bin/
GetTRDoc?AD=ADA084551&Location=U2&doc=GetTRDoc.pdf.
20. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and
Giroux; 2011.
21. Moulton CA, Regehr G, Lingard L, et al. “Slowing down when you should”:
Initiators and influences of the transition from the routine to the effortful. J
Gastrointest Surg 2010; 14: 1019–26.
22. van Ryn M, Saha S. Exploring unconscious bias in disparities research and
medical education. JAMA 2011; 306: 995–96.
23. Brater DC. Viewpoint: Infusing professionalism into a school of medicine:
Perspectives from the dean. Acad Med 2007; 82: 1094–97.
24. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary
approach to promoting professionalism: Identifying,measuring, and addressing
unprofessional behaviors. Acad Med 2007; 82: 1040–48.
21
Chapter 3
Current Practices in Remediating Medical
Students with Professionalism Lapses
Deborah Ziring, MD, Suely Grosseman, MD, PhD, and
Dennis Novack, MD
A
lthough professionalism has been a concern for the past three decades, little is known about best practices in remediation of professionalism lapses. In 2002, in response to concerns about changes
in health care delivery that were threatening physician professionalism, a
collaborative effort by leaders of the American Board of Internal Medicine
(ABIM) Foundation, the American College of Physicians-American
Society of Internal Medicine (ACP-ASIM) Foundation, and the European
Federation of Internal Medicine produced the Physician Charter.1 This
work emphasized three fundamental principles of professionalism: the
primacy of patient welfare, patient autonomy, and social justice. The imperative, however, for identifying students with lapses early in their education was not fully appreciated until 2004, when Papadakis et al. linked
professionalism lapses in medical students with future disciplinary action
by state medical boards.2 Subsequently, in 2008 the Liaison Committee
on Medical Education (LCME) implemented Element 3.5 (previously
Standard MS-31A), which requires medical schools to detail the methods
used to assess and remediate professionalism in their students.3 Yet no
consensus currently exists for defining professionalism in medical education, as evidenced by Birden’s 2014 systematic review of the literature on
this topic (though various definitions share many essential elements).4 In
addition, assessment is complex and must take into account the individual,
the existing interpersonal relationships, and the societal-environmental
factors present at any given moment.5 An individual’s professionalism is
dynamic, responding to competing demands and the organizational environment.6 The importance of institutional culture toward professionalism
and how lapses are handled has been previously documented by Hickson7
and Shapiro.8
This chapter includes content that was first published online at
www.academicmedicine.org and will appear in the July 2015 print issue of
Academic Medicine: Ziring D, Danoff D, Grosseman S, et al. How Do Medical
Schools Identify and Remediate Professionalism Lapses in Medical Students?
A Study of U.S. and Canadian Medical Schools. Academic Medicine. 2015;
90 (7). doi: 10.1097/ACM.0000000000000737. Used with permission of the
Association of American Medical Colleges.
23
Medical Professionalism: Best Practices
There is a growing consensus that professional formation is a developmental process.9,10 Helping learners to recognize professionalism conflicts and to navigate resolution when such situations arise is part of this
development.11 Inevitably, some students will make mistakes from which
they must learn. Still, little is known about best practices in remediation
at any stage across the continuum from medical school to practice.12 In
2011, Alpha Omega Alpha (AΩA) sponsored a think tank of experts in
medical professionalism that focused on interventions and remediation
strategies for medical professionalism lapses. This group called attention
to the paucity of information on evidence for best practices in remediating
professionalism lapses and recommended as one next step gathering data
on existing practices until evidence-based research could be conducted.13
For many years, the educational leadership at our institution, the Drexel
University College of Medicine (DUCOM) has been taking an ad hoc approach to the issues of how best to remediate and monitor our students
with professionalism lapses. In 2004, Dr. Papadakis visited DUCOM and
shared her work in this area. We had already been performing peer assessments with student feedback in the first year but had not established a formal process for remediating lapses throughout all four years. We also had
no systematic curriculum in professionalism education. By 2010, we had a
four-year longitudinal professional formation curriculum with professionalism graduation competencies. In 2012, our Professionalism Remediation
Advisory Board was created to formalize the professionalism remediation
process of our students. But we also wanted to know what other schools
were doing: What strategies and processes have been employed among
North American schools to identify and remediate lapses among medical
students? Since little data existed in the literature, we undertook a study
of LCME-accredited schools in the United States and Canada to analyze
the current practices on professionalism lapses and remediation that will
be described in this chapter.
Method
Since we were unable to identify a suitable survey instrument to collect all of the data we wanted to address in our survey, we developed one
based initially on questions from Swick et al.14 and Bennett et al.,15 with
additional questions added through an iterative process. Pilot testing was
carried out at two institutions; the questionnaire was then modified to the
version used for this survey. The version includes sixteen open and closedended questions. Questions addressed the following four areas:
1. Professionalism policies
2. Identification of students with lapses
3. Administrative response to lapses
24
3. Current Practices in Remediating Medical Students with Professionalism Lapses
4. Remediation practices
After the first forty-seven schools were interviewed, three additional
questions regarding examples of lapses were added to identify student
behaviors that triggered remediation. These three additional questions
were e-mailed to all previously interviewed respondents and included
during all subsequent phone interviews. The final survey questionnaire is
in the Appendix.
Before recruitment of participants began, a letter of determination
was sent to Drexel’s IRB that determined that this project was not human
subject research. Subject schools were identified using the Association of
American Medical Colleges (AAMC) list of accredited schools accessed
on April 25, 2012. E-mails were sent to the education deans at each school
explaining the study and asking for the contact information for the key
person(s) at their institution responsible for medical student professionalism remediation. Follow-up by e-mail and phone was conducted at one
and two weeks after the initial e-mail. Once identified, this key person was
contacted with an e-mail detailing the study and requesting participation
in a thirty-minute phone interview. Once an interview was scheduled,
respondents were e-mailed the questionnaire at least twenty-four hours
prior to the structured phone interview. All interviews were conducted
by one of two interviewers who had received three hours of training. All
phone interviews were recorded and transcribed. A ten percent sample
was reviewed for accuracy. Data collection occurred from June 2012 to
April 2013.
A mixed-methods approach was utilized for data analysis. Quantitative
data were de-identified and inserted into SPSS (IBM SPSS Statistics.
Version 20. Chicago: IBM; 2012.). An impartial third party reviewed quantitative data entries. Basic descriptive analysis of this data was performed
and x2 tests on select data were performed. Qualitative analysis was performed after loading transcripts into Atlas.ti (Version 7. Berlin: Scientific
Software Development GmbH; 2012.), guided by procedures based on
grounded theory.16 Researchers discussed emerging results throughout
the coding and analysis process to minimize the effect of a single analyst
bias. Qualitative analysis was directed to three areas:
1. Anonymous reporting
2. Sharing information about struggling students (feed-forward
practices)
3. Respondents’ perceptions of system strengths and weaknesses
Results
Ninety-three of 153 invited schools participated (60.8). Ninety of
those schools completed the questionnaire by telephone interview, while
25
Medical Professionalism: Best Practices
three schools completed it in writing. Sixty-six schools (71 of sample)
responded to the three additional questions regarding specific examples
of professionalism lapses. Eighty-one of the ninety-three schools were
located in the United States (87.1 of sample and 59.6 of eligible U.S.
schools) and twelve were in Canada (12.9 of sample and 70.6 of eligible
Canadian schools). Using the regional designations of the AAMC Group
on Educational Affairs (GEA), response rates by region were Northeast
56.0 (28 of 50 schools), South 54 (27 of 50 schools), Central 68.6 (24
of 35 schools) and West 77.8 (14 of 18 schools). Entering class size among
respondents for academic year 2012–2013 ranged from forty-two to 362
students with most schools having between 100 and 200 students.17 Seven
of the schools received their first matriculating class less than five years
ago. These are identified as “new schools” in this report.
Schools’ written policies and procedures regarding professionalism
lapses
Most respondents (79.6) reported that their schools had written
policies and procedures regarding medical student professionalism
lapses. Many of them provided those documents or links to access them.
Although formal qualitative analysis of these policies is not yet available,
elements commonly seen were descriptions of expectations, mechanisms
for reporting lapses, and potential consequences for lapses, as well as
linkage to university or other umbrella policies. While some policies
contained broad generalizations about conducting oneself in a professional manner, others contained very detailed descriptions of behaviors
expected, as well as specific procedures and consequences for different
types of lapses.
Administrative oversight
The administrative oversight of this process was complex. We asked:
When unprofessional behavior is identified and requires a response beyond immediate feedback, who is initially notified? At the majority of
schools, such a lapse was reported to the course director and/or student
affairs dean, often simultaneously. In about 20 of respondent schools,
initial reporting was to the medical education dean. At about 5 of
schools, it was initially reported to the professionalism director, promotions committee, or honor court. The course director and student affairs
dean determined the course of action, devised the remediation and oversaw the remediation at the majority of schools as detailed in Table 1 below.
Promotions committees had a larger role in the latter stages of this process, such as determining the action after a lapse, devising remediation,
26
3. Current Practices in Remediating Medical Students with Professionalism Lapses
and assessing the outcome of remediation, than they did at the initial
notification or oversight of remediation phases.
Table 1. Administrative Oversight of Professionalism Lapses of Medical Students
among 93 U.S. and Canadian LCME-Accredited Schools
(June 2012–April 2013)
na (%)b
Person/
Committee
Notified
initially
about
lapse
Assesses
Determines
Oversees
outcome of
action
Devises
after lapse remediation remediation remediation
Student
affairs dean
69 (74.2)
54 (58.1)
46 (49.5)
48 (51.6)
45 (48.9)
Course or
clerkship
director
63 (67.7)
30 (32.3)
44 (47.3)
37 (39.8)
38 (41.3)
Medical
education dean
19 (20.4)
26 (28.0)
17 (18.3)
19 (20.4)
16 (17.4)
Professionalism
director
5 (5.4)
8 (8.6)
9 (9.7)
10 (10.8)
9 (9.8)
Promotions
committee
5 (5.4)
35 (37.6)
41 (44.1)
20 (21.5)
40 (43.5)
Honor court
4 (4.3)
9 (9.7)
9 (9.7)
6 (6.5)
6 (6.5)
Medical school
dean
2 (2.2)
3 (3.2)
3 (3.2)
0 (0)
3 (3.2)
Other
6 (6.5)
9 (9.7)
12 (12.9)
9 (9.7)
11 (12.0)
a
The count of schools in each column totals to more than 93 because some schools involved
more than one administrator at a time and/or have different system pathways depending
on student progress through the program (preclinical or clinical), lapse severity, and/or frequency of lapses.
b
The denominator for percent determination is 93, not the total n in each column.
Identification of lapses
Mechanisms used to identify professionalism lapses were incidentbased reporting, items on routine student evaluations, a separate professionalism course with grade, formal peer assessment, and anonymous
reporting.
27
Medical Professionalism: Best Practices
Eighty-eight percent of schools (82/93) used an incident-based reporting system in the preclinical years, while 92.1 (82/89) used it in the
clinical years. Some respondents from new schools that did not yet have
students in the clinical years could not respond to certain questions. Many
schools also routinely collected information about professionalism on
student evaluations. During the clinical years, 97.8 of schools (88/90)
used routine student evaluations in all clerkships and courses to collect
information about student professionalism. The two schools that did not
collect this information for all courses/clerkships during the clinical years
excluded non-patient care courses such as an intersession. Sources of
information for evaluations during the clinical years were faculty, house
staff, other health care professionals, patients, and/or their families.
During the preclinical years, 43.5 of schools (40/92) used routine student
evaluations in all courses to collect professionalism information, and another 37.0 (34/92) collected this information in some courses.
Fifteen percent of respondents indicated that they had a separate professionalism course and grade. Forty-five percent of schools (41/92) used
formal peer assessment in the preclinical years, while 16.7 (15/90) used
it during the clinical years. All schools that used peer assessment during
the clinical years also used it during the preclinical years. Frequency of
peer assessment at schools that used it was quite variable. At some schools
assessment was performed annually, while at other schools repeated assessments provided multiple data points throughout the year, often at the
end of a module or block.
Half of the respondent schools (46/92) reported that they had a
mechanism for anonymous reporting (i.e., no information about reporter
required). The existence of an anonymous reporting system was not statistically different among schools in different geographic regions (x2=3.67,
p=0.30) or class size (x2=3.25, p=0.52). However, qualitative analysis indicated that assessing anonymous reporting was not straightforward. For
example, some schools with an anonymous reporting system indicated
that no action could be taken on a report submitted anonymously; therefore no help could be directed toward a student with a professionalism
lapse unless the lapsing student had a chance to address the reporting
student’s concerns. Such a system effectively negates any practical utility of an anonymous reporting system. In addition, many schools with a
so-called anonymous reporting system were actually using a confidential
system in which a reporting student was identified to the administration
handling the report but remained unknown to the student reported.
28
3. Current Practices in Remediating Medical Students with Professionalism Lapses
Most common lapses cited
Sixty-six respondents of the ninety-three schools (71) reported their
perceptions about the three most common professionalism lapses at their
institutions, resulting in 183 responses. We categorized these responses
using Papadakis’ proposed categorization of lapses, which is based on
four behavioral domains (presented at the 2013 AΩA Professionalism
Meeting).18 These categories are described more completely in Chapter 1
of this monograph, but are:
1. Responsibility (e.g., late or absent for assigned activities, missing
deadlines, unreliable)
2. Diminished capacity for self-improvement (e.g., arrogant, hostile, or
defensive behavior)
3. Relationship with patients, including communication with patients
4. Relationship with health care environment (e.g., testing irregularities, falsifying data, or impaired communication with team).
Lapses in responsibility were most common (n=102, 55.7), followed by
lapses related to the health care environment (n=59, 32.2), diminished
capacity for self-improvement (n=18, 9.8), and lapses in relationship with
patients (n=4, 2.2). Academic dishonesty, including cheating and plagiarism, accounted for twelve (7) of total responses, but made up 20 of the
lapses in the domain of relationship with health care environment (12/59).
Certain professionalism lapses were grounds for dismissal at some
schools and not remediated. These included committing a felony, falsifying patient information, falsifying information on a residency application, forging a prescription, not reporting for clinical call, or research
misconduct endangering safety. Some respondents reported cheating on
an exam as grounds for dismissal, while others remediated this behavior.
In addition, respondents cited an ongoing pattern of repeated offenses or
lack of adherence to a prescribed remediation plan as potential grounds
for dismissal.
Remediation strategies
Schools remediating professionalism lapses used a variety of strategies,
as listed below in Table 2. Schools were asked to include all strategies
that they have employed for remediation regardless of the frequency with
which they used that strategy.
29
Medical Professionalism: Best Practices
Table 2. Strategies for Remediation among 93 U.S. and
Canadian LCME-Accredited Schools (June 2012–April 2013)
Strategy
n (%)a
Mandated mental health evaluation/treatment
74 (82.2%)
Complete professionalism assignment
66 (73.3%)
Mandated professionalism mentor
66 (73.3%)
Counseling for stress or anger management
65 (72.2%)
Repeat part or all of course/clerkship
59 (64.8%)
Mandated community service
15 (16.6%)
Other
04 (04.4%)
a
Percent is calculated using n=90 schools, since three schools had new programs and had
not yet remediated any students.
In general, schools combined a number of strategies to remediate
professionalism lapses depending on the particular details of the lapse.
A number of respondents indicated that decisions regarding remediation were determined on a case-by-case basis rather than by a formalized
structured approach. Many respondents stressed the critical importance
of initial dialogue with the student to evaluate student stress and mental
health in addition to the details surrounding the lapse when devising a
remediation plan.
In regard to mental health evaluation and treatment, some respondents
referred students to school-employed practitioners, while others utilized
external programs established for physicians but not specifically designed
for students. Similarly, stress management and counseling was conducted
through either internal school-based programs or through “arms-length”
external programs.
The details of how mandated professionalism mentors were employed
varied considerably. Individuals assigned as mentors included deans, faculty members, advisors, course directors, or professionalism program directors. Mentor-mentee meeting frequency was individualized depending
on the situation. The number of follow-up meetings varied from a total of
three meetings to as often as weekly for the duration of the student’s enrollment at the medical school. The mentor and mentee most often spent
their time together discussing the specific professionalism lapse, reviewing completed professionalism assignments, and/or discussing general
professionalism issues.
The assignments employed for remediation fell largely into two categories: reading and writing broadly about general professionalism issues or
focusing selectively on the specific behavioral lapse. Some examples were
30
3. Current Practices in Remediating Medical Students with Professionalism Lapses
directed reading with reflective writing, doing a literature review culminating in a paper/presentation, or reviewing targeted videos of professionalism lapses and critiquing them. In addition, some schools required
students to review their school’s policies relevant to the lapse or assist
with developing new policies if no explicit policy existed. This strategy
was mentioned several times—for instance, in developing or expanding
social media policies. Other assignments included a required public apology to the group affected by the lapse or a private apology to an individual.
Attendance at disciplinary committee meetings was sometimes required,
which could be at the school, hospital, or state level. One school required
a student with academic dishonesty to write a reflective piece from a future patient’s point of view on finding out about the student’s lapse during
medical school.
When professionalism behavioral objectives were not met, instead of
requiring the student to repeat part or all of a course/clerkship, some
schools assigned an additional course or clerkship including, for example,
a special bio-psychosocial elective with a focus on professionalism.
The respondents that employed community service as remediation
reported that they used it in two general circumstances: when the intent was to make the student better understand the physician’s roles and
responsibilities within the community by assigning him to work with a
disadvantaged group, or for someone considered to be lacking in empathy.
One problem in applying this strategy is that organizations often do not
want someone mandated to serve instead of a willing volunteer.
In addition to these specific strategies, other elements included the following. Some respondents issued a behavioral or remediation contract to
students for lapses requiring remediation. Typically these documents outlined clear behavioral expectations that the student was required to meet,
as well as the consequences for violation, including the potential for dismissal. Some schools officially put students on probation when they were
undergoing professionalism remediation. Some respondents stated that if
they put a student on probation, it was automatically noted on their Dean’s
letter for residency, but others expressed reluctance to include this information. The effect of academic suspension or repeating coursework that
could result in delayed graduation and impact the residency application
cycle was also mentioned as a consideration in the remediation process.
Although respondents largely employed the same range of strategies for
professionalism remediation, the responses at different schools for similar
lapses were quite variable. For example, for a lapse regarding cheating,
some schools allowed the student to retake of the exam under supervision
without further consequences, other schools required professionalism
remediation, while still others dismissed the student outright.
31
Medical Professionalism: Best Practices
Adding to this variability in handling lapses was the school’s culture
toward professionalism lapses. Some schools had a more punitive culture
that relied on strong warnings and consequences for violations, including
dismissal rather than remediation. Other schools took a developmental
view and conveyed the attitude that lapses were a natural part of professional formation and an opportunity for education. In addition, some
schools expressed more tolerance in the preclinical years regarding tardiness and other lapses of responsibility than during the clinical years when
patient care was involved. Consider the following two representative
quotes of these different views:
“Stern warnings are the most effective form of remediation.”
“Most critical is to understand that these are young people who need professional
development and not punishment. They are not professionals yet, they are training
to be professionals.”
Feed-forward practices
Forty-nine schools (52.7) reported that they did forward feed information about professionalism lapses, while thirty-nine (41.9) did not. Five
schools (5.4) indicated that decisions regarding forward notification
depended on the stage of training and type of lapse. For example, they did
not forward feed information on lapses of responsibility such as tardiness
or dress code infractions, particularly during the preclinical years, but did
share this information if patient safety was involved.
Feeding forward of information about students who had lapsed usually occurred via course/clerkship directors and did not go to the faculty
member directly supervising the student. Feed-forward practices showed
no statistically significant differences between schools in different geographic regions (x2=5.83, p=0.44) and among different class sizes (x2=7.19,
p=0.52).
Qualitative analysis of responses related to forward feeding policies
revealed more complexities in the decision to forward feed, practices
used to forward feed, and some of the considerations in employing or not
employing a forward feeding policy. First, it was clear that more schools
forward feed information about lapses than the quantitative data suggest. This may be related to how respondents understood the question.
Respondents who reported that their schools did not generally forward
feed information stipulated instances in which they would (e.g., if patient
safety was a concern). In those instances they typically did so only to
individuals who did not directly supervise a student to avoid any grading
32
3. Current Practices in Remediating Medical Students with Professionalism Lapses
bias. For example, one respondent who reported they did not forward feed
qualified it by saying,
“There’s no blanket rule. It depends on the nature of the incident and the level of
confidentiality, which wins out in that particular situation.”
One of the most common themes related to forward feeding was doing
so in order to help students rather than punish them.
“[Previously problematic] behavior is tracked between clerkships. That information
is passed onto the next clerkship. ‘John Doe struggled with such and such, place
him with a strong mentor.’ In a supportive, not [punitive] way. It’s more of, how can
we put him with a good role model who will give him feedback early and continue
the [supportive] environment?”
Often forward feeding did not follow a written protocol but was conducted through discussion in monthly course/clerkship director meetings.
This tied into the idea of helping students and making sure they were
supported as they moved forward; some schools did not consider this a
formal feed-forward policy, however.
“We do have a meeting every month with the Clerkship Chairs and Course Chairs
from the pre-clinical years. We do share the physicianship information and often
will pick . . . the site where that student is going to be for a clerkship based on the
level of supervision we know is present at that site.”
Creating biases because of forward feeding was a common concern. For
some schools this led to a policy against forward feeding.
“This is a delicate problem if somebody has professionalism difficulties. We think
it’s probably not a good idea [to feed forward]. Somebody having academic difficulties, that information gets passed forward. But somebody having professionalism
problems, we try to have a clean slate going on to another clerkship, as an example.”
Overall, almost all schools did discuss some instances in which they
would forward feed information about professionalism lapses, even if
their general policies were not to do so.
Faculty issues
At almost all respondent schools, faculty members were expected
to directly address professionalism lapses with students when they occurred. This was a written policy at twenty-seven schools (29) and an
33
Medical Professionalism: Best Practices
expectation at sixty schools (64.5). Thirty-two schools (42.4) had a
formal faculty development program to train faculty for this role. We
included all schools that performed any faculty development in this tally,
including schools that did not have robust programs as well as those that
had optional programs such as annual faculty development seminars on
this topic.
Criteria for success
Whatever the remediation strategy, the criteria for successful remediation were not well defined. Success could be determined by the course/
clerkship director who directly supervised the student, an assigned professionalism mentor, or by a promotions committee that officially voted
on this issue. Respondents that used a behavioral contract cited the
benefit of using that contract to outline what constituted success at the
beginning of the remediation process to minimize the issue of variable
perspectives of success.
Participants’ perceived strengths of their remediation systems
Most strengths identified could be placed into the following four main
themes:
1. Catching minor offenses early to help students before problems
escalate
2. Emphasizing professionalism school-wide
3. System focusing on helping students rather than punishing them
4. Assuring transparency and good communication
Many respondents that focused on catching minor offenses early
had employed a variant of the University of California, San Francisco,
Physicianship Evaluation system. Some respondents emphasized professionalism through formalized teaching strategies, weaving components of
professionalism education and standards throughout the curriculum, or
simply working on the culture surrounding identification and reporting
of lapses so that it was seen as less negative. One respondent noted their
progress in emphasizing professionalism,
“I think people are much more aware of professionalism. They’re more aware that
they can comment on it and address it. The students are more aware that we care
about it and they’re actually doing a bit more kind of peer assessment and reporting on each other when the lapses are significant. I think the structure is forming
where people know how to bump up concerns around professionalism and activate
our Academic Progress Committee more frequently.”
34
3. Current Practices in Remediating Medical Students with Professionalism Lapses
Emphasizing professionalism and re-orienting school culture to one
that supports rather than punishes students who lapse was also commonly
noted among system strengths. As one respondent nicely summarized
why professionalism systems should focus on helping students and catching offenses early,
“Sometimes students don’t understand how to act in the culture of a hospital as
well as are stressed out, tired and worried about grades and they sometimes do
things in the heat of the moment that they normally wouldn’t do.”
Many respondents noted that transparent policies including clear professionalism expectations of students and consequences of lapses were
critical to ensuring students understood the importance of professionalism both during school and for their future careers.
Participants’ perceived weaknesses of their remediation systems
Four major themes were identified as system weaknesses. These were:
1. Reluctance to report (among both students and faculty)
2. Lack of faculty training
3. Unclear policies
4. Remediation ineffective
Factors cited for reluctance to report were faculty discomfort in determining the seriousness of the problem, the increased workload that
reporting creates for them, concern about harming the student’s future,
that a witnessed lapse seems minor, and fear of repercussions.
Reluctance to report can work directly against early identification of a
problem that could be easily addressed and remediated. One respondent
noted that their school’s major weakness was
“. . . reluctance of [faculty] to step forward and meet with students directly about
professionalism incidents. I think . . . , things get escalated too far that maybe an
earlier intervention could have had a more positive outcome.”
Many respondents felt that reluctance to report, at least among faculty,
could be overcome with better faculty training, which was identified as a
system weakness. The challenge of training clinical faculty with typically
high turnover rates was cited by several schools as problematic. Some
respondents felt faculty reluctance to report could also be overcome with
clearer policies so that both students and faculty better understood expectations. A few respondents noted that the problem of defining professionalism itself leads to policy murkiness.
35
Medical Professionalism: Best Practices
“There are some physicians in practice who work with our institution who are not
fond of the term professionalism. They feel that it’s being used too loosely and
doesn’t give the students an adequate and clear definition of what the expectations
are and how those are measured and what that means.”
Respondents commonly reported that their administrations struggled
with remediation in a larger sense. Some of them felt that remediation
simply did not work for specific lapses or certain students. One respondent noted debate at the institution over how to remediate issues resulting
from certain personality types.
“I think those students . . . who are arrogant, really arrogant, or who are narcissistic . . . There are certain personality types that can figure out how to make it
through what we do for remediation but who, I think, will never be beacons for
professionalism. And I worry about that. We last month voted on dismissing a student on professionalism, you know? A student, who just has been followed by the
Promotions Committee for two years. And was in a contract and still is exhibiting
this very arrogant [behavior]. So, unfortunately, I’m not sure if we’ve found a way
to really remediate those students who I’m most concerned about.”
Beyond expectations and policies
One respondent noted that understanding professionalism and making systems work can be about more than expectations and policies. It is
important to remember the “cultural” differences between students and
faculty and how those will be constantly evolving as programs grow and
change through time.
“What students understand to be professionalism and what faculty consider to
be professionalism can be of some variance that needs to be considered (cultural
differences). Faculty can make assumptions of what the incoming students should
know already in terms of professionalism and that might not be the case because
everyone is coming from different generational perspectives, so, they have to take
advantage of the opportunities to turn incidents into learning events to teach students what faculty expect in certain circumstances.”
Conclusions and discussion
The current study is the first to take a comprehensive look at medical
schools’ remediation practices. The quality and extent of a school’s remediation system is crucial because it signals to both students and faculty
the school’s commitment to the professional development of its students.
Student affairs deans and course directors are responsible for addressing
the great majority of lapses. It is notable that a minority of schools had
36
3. Current Practices in Remediating Medical Students with Professionalism Lapses
a director overseeing professionalism education and remediation. The
findings revealed considerable variation in the policies and procedures
to identify and intervene in addressing lapses in professionalism. The
identification of lapses varied among schools, with some having few, and
others very elaborate mechanisms for identifying these students. All of
these mechanisms are limited, though, as our respondents suggested,
by differing conceptions of professionalism among faculty and students,
reluctance to report, and mistrust of the reporting system. Though peer
assessment has been found to be a valuable means of providing feedback
to students and faculty,19 fewer than half of responding schools used this
method in the preclinical years, and only a small percentage during the
clinical years.
Using the organizational framework for lapses based on the behavioral domains proposed by Papadakis at the 2013 AΩA professionalism
meeting,18 lapses in responsibility were reported by our respondents as
most common. In her 2005 work, Papadakis et al. found that lapses in the
domain of responsibility had the highest odds ratio of 8.5 for subsequent
disciplinary action.20 Although individually seen as “minor” lapses, identification of these lapses with formative feedback to students when they
occur would be important to promote correction of problematic behaviors
and connect the implications of behavior with the expected professionalism ideals in the practice of medicine. In addition, Ainsworth found that
student response when confronted with the report of a professionalism
lapse was a better predictor of subsequent lapses than was the type of behavior that triggered the report. Students with diminished capacity to recognize that their behaviors were unprofessional or who were unwilling to
accept responsibility for their behaviors were at high risk for subsequent
lapses.21 Tracking these “minor” lapses longitudinally so that patterns
could be discerned, with remediation and monitoring when repetitive,
would likely be beneficial.
Some of the remediation practices employed were designed to emphasize this connection to professionalism ideals, such as those employing reflective writing assignments and meetings with professionalism
mentors. Also, it is clear that faculty often “diagnose” the root cause of
professionalism lapses to be mental health problems, as evidenced by the
frequent usage of mandated mental health evaluations and counseling for
stress and anger management. This is not surprising considering the high
rates of depression, anxiety, and burnout among medical students.22–24
Several study limitations should be noted here. First, while our response rate was better than many comparable studies,25 the study may be
subject to sampling bias, including voluntary response and nonresponse
biases. The former may have led to inclusion of schools more interested in
37
Medical Professionalism: Best Practices
professionalism, while the latter may have led to data that reflects schools
most active in professionalism reporting and remediation. Second, though
we attempted to minimize the effect of “undercoverage” by considering
AAMC region and class size, our sample may not be truly reflective of all
schools. Third, the complexity of the remediation process and wording of
some questions may have led to confusion among respondents, given their
variable levels of expertise.
Despite these limitations, our study has significant strengths. By compiling this data, we have created the first inventory of current practices
for identifying and remediating professionalism lapses among medical
students. We have called attention to the current unnecessary variability within and among schools that would be well served by consensus
guidelines for best practices in this area. The Association of Faculties
of Medicine in Canada (AFMC) has recently published such consensus
guidelines for designing professionalism remediation for undergraduates,
postgraduate trainees, and faculty members in Canada.26
We think that the themes we have identified as system strengths may
hold promise in formulating such a best practices approach to remediation including:
1. Catching minor offenses early to help students before problems escalate requires that a graded response to lapses be utilized.
2. Emphasizing professionalism school-wide, with clear definitions
of expected behaviors and consequences, including remediation when
students fall short.
3. Focusing on helping students rather than punishing them, so that
personal and professional growth is supported.
4. Assurance of transparency and good communication, with a welldefined process for reporting and tracking.
Tackling faculty reluctance to report through robust training so that
faculty members understand the significance of “minor” lapses and
feel more comfortable having those initial crucial conversations when
sub-optimal professional behaviors are encountered would foster early
identification of students with lapses so that they could be helped. A
longitudinal view of student performance in this area would need to be
included in a best-practices approach so that patterns of lapses could be
identified and monitored. Since the responsibility for professionalism
remediation seems diffuse at many institutions, specific responsibility for
this role needs to be clearly defined, with resources to mentor and track
student progress. It is clear that feed-forward policies are not straightforward and consensus on this issue is lacking, as has been previously
reported in the literature.27–30 The components of this approach are very
38
3. Current Practices in Remediating Medical Students with Professionalism Lapses
similar to those previously outlined by Hickson on the infrastructure necessary for promoting reliability and professional accountability.7
We recommend several immediate next steps:
1. Create an online repository of robust examples of school policies and
procedures, behavioral contracts, and remediation assignments so schools
can easily share successful practices and build on existing resources.
2. Provide robust faculty training to enhance skills and knowledge in
addressing lapses and early reporting.
3. Explore further the risks and benefits of feed-forward practices.
4. Investigate the factors contributing to underreporting so they can
be addressed.
In the long term, we recommend effectiveness studies of identification
and remediation strategies as measured through student outcomes.
Acknowledgments
The authors thank the following colleagues who contributed to the original survey
project described in this chapter: Deborah Langer, MPA; Deborah Danoff, MD;
Amanda Esposito, MS4; Mian Kouresch Jan, MS4; and Steven Rosenzweig, MD.
We would also like to thank our colleagues at all of the participating institutions
for their thoughtful contributions to this work and their insightful comments.
References
1. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM
Foundation, American College of Physicians-American Society of Internal
Medicine; European Federation of Internal Medicine. Medical professionalism
in the new millennium: a physician charter. Ann Intern Med 2002; 136: 243–46.
2. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional
behavior in medical school is associated with subsequent disciplinary action by a
state medical board. Acad Med 2004; 79: 244–49.
3. Liaison Committee on Medical Education. Functions and Structure of
a Medical School: Standards for Accreditation of Medical Education Programs
Leading to the M.D. Degree. Washington DC: Liaison Committee on Medical
Education; 2014. Available at: http://www.lcme.org/publications/2015-16functions-and-structure-march-2014.doc.
4. Birden H, Glass N, Wilson I, Harrison M, et al. Defining professionalism in
medical education: A systematic review. Med Teach 2014; 36: 47–61.
5. Hodges BD, Ginsburg S, Cruess R, et al. Assessment of professionalism:
Recommendations from the Ottawa 2010 Conference. Med Teach 2011; 33:
354–63.
6. Lucey C, Souba WC. Perspective: The problem with the problem of
professionalism. Acad Med 2010; 85: 1018–24.
7. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary
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approach to promoting professionalism: Identifying, measuring, and addressing
unprofessional behaviors. Acad Med 2007; 82: 1040–48.
8. Shapiro J, Whittemore AW, Tsen LC. Instituting a culture of professionalism:
The establishment of a center for professionalism and peer support. Jt Comm J
Qual Patient Saf 2014; 40: 168–77.
9. Parker M, Luke H, Zhang J, et al. The “pyramid of professionalism”: Seven
years of experience with an integrated program of teaching, developing, and
assessing professionalism among medical students. Acad Med 2008; 83: 733–41.
10. Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional formation:
Extending medicine’s lineage of service into the next century. Acad Med 2010;
85: 310–17.
11. Cruess RL, Cruess SR, Steinert Y, editors. Teaching Medical Professionalism.
New York: Cambridge University Press; 2008.
12. Hauer KE, Ciccone A, Henzel TR, 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: 1822–32.
13. Papadakis MA, Paauw DS, Hafferty FW, et al. Perspective: The education
community must develop best practices informed by evidence-based research to
remediate lapses of professionalism. Acad Med 2012; 87: 1694–98.
14. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism
in undergraduate medical education. JAMA 1999; 282: 830–32.
15. Bennett AJ, Roman B, Arnold LM, et al. Professionalism deficits among
medical students: Models of identification and intervention. Acad Psychiatry
2005; 29: 426–32.
16. Charmaz K. Grounded Theory in the 21st Century: Applications for
Advancing Social Justice Studies. In: Denzin NK, Lincoln YS, editors. The Sage
Handbook of Qualitative Research. 3rd Edition. Thousand Oaks (CA): Sage
Publications; 2005: 507–35.
17. Barzansky B, Etzel SI. Medical schools in the United States, 2012-2013.
JAMA 2013; 310: 2319–27.
18. Papadakis M. Classifying lapses of professionalism around domains; An
organizational tool to determining best practices for remediation. Alpha Omega
Alpha Honor Medical Society Professionalism Meeting. New York; 2013.
19. Shue CK, Arnold L, Stern DT. Maximizing participation in peer assessment
of professionalism: The students speak. Acad Med 2005; 80 (10 Suppl): S1–S5.
20. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by
medical boards and prior behavior in medical school. N Engl J Med 2005; 353:
2673–82.
21. Ainsworth M, Szauter K. Classifying student responses to reports
of unprofessional behavior: A method for assessing likelihood of repetitive
problems. Association of American Medical Colleges Medical Education
Meeting. Philadelphia; 2013. https://www.aamc.org/download/357820/data/
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professionalismainsworth16.pdf.
22. Dyrbye LN, Harper W, Moutier C, et al. A multi-institutional study
exploring the impact of positive mental health on medical students’ professionalism
in an era of high burnout. Acad Med 2012; 87: 1024–31.
23. Dyrbye LN, Massie FS Jr, Eacker A, et al. Relationship between burnout
and professional conduct and attitudes among US medical students. JAMA 2010;
304: 1173–80.
24. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression,
anxiety, and other indicators of psychological distress among U.S. and Canadian
medical students. Acad Med 2006; 81: 354–73.
25. Baruch Y. Survey response rate levels and trends in organizational
research. Human Relations 2008; 61: 1139–60.
26. Association of Faculties of Medicine of Canada. Consensus Guidelines on
Designing Professionalism Remediation. Ottawa; 2013. https://www.afmc.ca/pdf/
committees/BOARD2013-IGProfessionalism.pdf.
27. Cleary L. “Forward feeding” about students’ progress: The case for
longitudinal, progressive, and shared assessment of medical students. Acad Med
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28. Cohen GS, Blumberg P. Investigating whether teachers should be given
assessments of students made by previous teachers. Acad Med 1991; 66: 288–89.
29. Cox SM. “Forward feeding” about students’ progress: Information on
struggling medical students should not be shared among clerkship directors or
with students’ current teachers. Acad Med 2008; 83: 801.
30. Frellsen SL, Baker EA, Papp KK, Durning SJ. Medical school policies
regarding struggling medical students during the internal medicine clerkships:
Results of a national survey. Acad Med 2008; 83: 876–81.
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Medical Professionalism: Best Practices
Appendix: Survey Instrument
Interview Unique Identifier:
Date/Time of Phone Interview:
Person(s) Conducting Interview:
Statement at beginning of interview: The goal of this project is to gather information about the current status of professionalism remediation in undergraduate medical education in the U.S. and Canada. We are inviting all AAMC member
schools to participate. We would like to speak to you for no more than 30 minutes.
All materials gathered will be confidential. The data collected will only be used in
the aggregate with no specific schools identified. However, if a particular school
has an exceptional program in this area, they may be contacted separately for
permission to identify their school and program. At the end of our work, we will
provide a draft of our final paper.
We would like to record this phone interview in case we need it for further review
during our study. May I have your permission to record this interview?
__Yes
__No
Would you like us to read you the questions off the survey, or would you like to
read it yourself and answer the question?
Part I. Your school’s policies and documents
1. How may we get a link to, or copy of, your school’s professionalism graduation
competencies (exit objectives)?
2. Does your school have a student code of conduct that is posted on the web,
included in your student handbook, or made available to students in some
other way?
__Yes
__No
3. Does your school have a written policy for responding to unprofessional behavior incidents? This may include a list of trigger or sentinel events. It may
include criteria for escalation of response, remediation, censure, penalty or
automatic dismissal.
__Yes
__No
Would it be possible to receive a copy of these documents for our research?
Part II. How your school identifies students with professionalism issues
4. Should a faculty member or administrator witness a student behaving unprofessionally, is there a policy or an expectation that the faculty member or
administrator will provide direct feedback to the student?
___Yes, a formal policy
___Yes, an expectation
___No
5. What are the three most common unprofessional behaviors identified at your
school?
42
3. Current Practices in Remediating Medical Students with Professionalism Lapses
6. If unprofessional behaviors require a response that goes beyond direct feedback given by the individual who witnessed it, how are these students identified for the next level of response? Please check all that apply.
a) Preclinical years:
I) Incidence Based Reporting: Do you have incident-based reporting of unprofessional behavior?
__Yes
__No
Who is this information reported to (what is his or her title)?
II) Routine Periodic Evaluation of Professionalism: Types of collection
mechanisms
Do you use standard or routine course evaluations that include professionalism information?
a. Does not use
b. Use for ALL courses
c. Use for SOME courses
Is there a separate professionalism course for which students receive
a separate professional evaluation?
__Yes
__No
If yes, please explain the course and how they are evaluated:
Do you utilize formal peer-assessments?
__Yes
__No
If yes, please explain how these assessments occur and how often:
b) Clinical years:
I) Incidence Based Reporting: Do you have incident-based reporting of unprofessional behavior?
__Yes
__No
Who is this information reported to (what is his or her title)?
43
Medical Professionalism: Best Practices
II) Routine Periodic Evaluation of Professionalism: Types of collection
mechanisms
Do you use standard or routine course evaluations that include professionalism information?
a. Does not use
b. Use for ALL courses
c. Use for SOME courses
Is there a separate professionalism course for which students receive
a separate professional evaluation?
__Yes
__No
If yes, please explain the course and how they are evaluated:
Is professionalism a component of every clinical evaluation form?
__Yes
__No
Do you utilize formal peer-assessments?
__Yes
__No
If yes, please explain how these assessments occur and how often:
III) Do other individuals, such as house staff, patients, and/or nurses, provide feedback about professionalism of students? How?
IV) Is the process different when a student is on an away elective?
c) Does the school have a mechanism for anonymous reporting of unprofessional student behaviors?
__Yes
__No
If yes, please describe:
Part III: Response to unprofessional behavior
7. When unprofessional behavior is identified and requires a response beyond
immediate feedback, who is initially notified?
a) Course or clerkship director
b) Student Affairs dean
c) Faculty Director of Professionalism Program
d) Dean
e) Other
44
3. Current Practices in Remediating Medical Students with Professionalism Lapses
8. Who determines the course of action to be taken? This might include determination that the incident is resolved, referral to Honor Court, referral
to Promotions Committee, recommendation for dismissal, or initiation of
remediation?
a) Course or clerkship director
b) Student Affairs dean
c) Faculty Director of Professionalism Program
d) Dean
e) Other
9. Regarding the response to unprofessional behavior, please explain the role of:
a) Honor Court/Student Professional Conduct Committee
b) Promotions Committee
c) Committee of Faculty or Administrators convened specifically to review unprofessional conduct
d) Student Affairs Dean
e) Other Individuals or Groups (please identify by title)
10. Do you have a faculty development program to train faculty how to respond
to professionalism issues?
__Yes
__No
If yes, please describe:
Part IV: Remediation
11. When a student is referred to remediation, who devises the remediation?
a) Course or clerkship director
b) Student Affairs dean
c) Faculty Director of Professionalism Program
d) Dean
e) Other
12. Who oversees the remediation?
a) Course or clerkship director
b) Student Affairs dean
c) Faculty Director of Professionalism Program
d) Dean
e) Other
45
Medical Professionalism: Best Practices
13. Who assesses the outcome of the remediation?
a) Course or clerkship director
b) Student Affairs dean
c) Faculty Director of Professionalism Program
d) Dean
e) Other
Explanation:
14. What strategies are utilized for remediation of unprofessional behaviors?
a) Repeat course/clerkship
b) Repeat course/clerkship with faculty supervision regarding professionalism
deficit
c) Mandated professionalism mentor:
Who is assigned?
How often do they meet?
d) Stress management counseling
e) Remediation curriculum or assignment
f ) Mandated mental health evaluation/treatment
g) Community Service
h) Other:
Explanation/Please provide an example so we can better understand your
process.
15. If a student has professionalism difficulties, is this information made available
to future supervisors?
__Yes
__No
If yes, explain the process of notification at your institution:
16. If a student has a significant professionalism incident, is there a standard,
monitoring process moving forward?
__Yes
__No
If yes, please describe:
17. What are some examples of the least serious unprofessional behaviors that
require remediation?
18. What are some examples of the most serious unprofessional behaviors that
require remediation?
19. What is working well with your current professionalism remediation strategies
and what do you see not working so well?
46
3. Current Practices in Remediating Medical Students with Professionalism Lapses
This concludes our interview. Thank you very much for taking the time to
share the information on professionalism remediation at your school. We
greatly appreciate it.
Is there anyone else we should contact at your school?
Name_______________________________________________
Title________________________________________________
Email contact_________________________________________
Phone number________________________________________
Do you have any questions?
47
Models
49
Chapter 4
Review of Current Models for Remediation
of Professionalism Lapses
Sheryl A. Pfeil, MD, and Douglas S. Paauw, MD
P
rofessionalism is one of the most basic tenets of medical practice. It is one of the ACGME core competencies and an expectation of every medical student, resident, and practicing physician.
Professionalism encompasses core professional beliefs and values, and
there is an assumption that all persons entering the medical profession
should have the aptitude and commitment to behave in a manner consistent with this value climate.1 The belief that the medical profession
should be held accountable to standards that are developed, declared, and
enforced by the profession itself is also a promise to society.2,3
The authors of the 2010 Carnegie report assert that professional identity formation—the development of professional values, actions, and aspirations—should be one of the four pillars of medical education.4 Despite
widespread agreement regarding the critical importance of teaching
professionalism in the medical curriculum and the importance of addressing unprofessional behaviors, there has been no clear consensus on best
practices with regard to the assessment of competency and remediation
of below-standard performance.1,5–8 On an individual level, professionalism is not a dichotomous trait but rather a behavioral response that can
be challenged by stressors and competing professional priorities.9–11
Furthermore, lapses can be a part of learning, and learners require education and guidance before becoming full professionals.1
Call to action
The expert participants in the 2011 Alpha Omega Alpha-sponsored
think tank on medical professionalism focused on interventions and remediation of professionalism lapses, with a consensus call to gather existing
practices on interventions and remediation that are used for medical students, residents, faculty, and practicing physicians, and to evaluate existing remediation practices via formal research.1 While data is still lacking
on best practices for the remediation of professionalism, there is general
agreement that remediation should be profession-led, that it should involve a diagnosis of the problem(s) and development of a learning plan,
that instruction and remediation activities need to occur, and that some
form of reassessment or follow up is needed to evaluate the adequacy
of the intervention.12–14 In this section, we outline some of the reported
practices for remediation of unprofessional behaviors with examples from
the published literature and from the authors’ experiences.
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Medical Professionalism: Best Practices
Programs for remediation of unprofessional behavior
The Vanderbilt University School of Medicine has established an approach for identifying, measuring, and addressing unprofessional behaviors.15 The Vanderbilt model is graduated, based on the severity of the
unprofessional behavior, with physician behaviors and corresponding
interventions stepped as a pyramid. The base of the pyramid includes
the vast majority of physicians who consistently behave in a professional
manner. Ascending up the pyramid, the next group encompasses those
physicians who have a single unprofessional incident. These incidents
are addressed by a conversation that serves as an informal intervention. The next step up the pyramid is when unprofessional or disruptive
behaviors recur as an apparent pattern. This pattern is addressed by an
awareness intervention that involves compiling and sharing data that sets
the physician apart from his or her peers. Most physicians respond and
make appropriate behavioral adjustments. However, a small proportion
of professionals seem unable or unwilling to respond to an awareness
intervention and develop a persistent pattern of unprofessional behavior.
These physicians require an authority intervention, with an improvement
and evaluation plan and ongoing accountability. Finally, there are the small
numbers of physicians at the tip of the pyramid who, failing to respond to
interventions, require disciplinary action and restriction or termination of
privileges and appropriate reporting to other entities. Other key aspects of
the Vanderbilt program include a supportive institutional infrastructure
that involves leadership commitment to addressing unprofessional behaviors, available surveillance tools, and training and resources for addressing
unprofessional behavior.
The Center for Professionalism and Peer Support at the Brigham and
Women’s Hospital (CPPS) is another exemplar program for addressing
unprofessional behavior.16 The CPPS does hear concerns about medical
student unprofessional behavior, but most reported concerns are about
physicians. The CPPS process, as previously outlined by Papadakis et al.,1
involves five steps. The first two steps are the reporting of the concern to
the CPPS and the investigation of the concern. The reporting conversation
is confidential, and the reporter is allowed to choose how to move forward
with the complaint, usually allowing the CPPS to further investigate the
concern. Multisource interviews are conducted to determine the validity
of the complaint and to obtain comprehensive input about the behavior
concern. The third step is a feedback conversation with the individual of
concern. The CPPS investigator and the individual’s supervising physician
meet with the individual to present feedback and to hear the individual’s
viewpoint. The focus is on the behavior, and there is a clear expectation
for behavioral change. A caring but straightforward approach is used,
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4. Review of Current Models for Remediation of Professionalism Lapses
acknowledging the frequent need for a combination of personal responsibility for behavior change and system change to facilitate a less stressful
environment. The specific behaviors that need improvement are summarized, and information is provided as to how the institution will follow
up to assure that the behavioral changes have occurred. Resources such
as personal coaching or educational resources are offered at this juncture,
but the individual decides how he or she can best facilitate the behavior
change.
If subsequent lapses occur, the process moves to the fourth step. At this
step, the institutional administration becomes involved, with a team that
may include a member of the CPPS, the chief medical officer, the department chair, or program director. Members of the administration team
meet with the individual to inform the person that the unprofessional
behavior has continued and that his or her institutional appointment
and employment are at risk. Interventions such as personal coaching,
behavioral programs, or an external evaluation may be required. The fifth
step in the process involves completing the loop by communicating with
the reporter of the complaint. This communication is balanced by the
competing need to maintain the privacy of the individual about whom
the concerns were raised. The reporter is informed that the institution is
addressing the concerns and that he or she should inform the institution
should the behavior continue or should there be retaliation. This process
demonstrates that professionalism concerns are taken seriously by the
institution, and that the value of professional behavior and culture of professionalism are supported.1
Both the Vanderbilt University disruptive behavior pyramid and the
Brigham and Women’s Hospital program predominantly focus on physician behavior. Along those same lines, Case Western Reserve University
has developed a remedial continuing medical education course (Intensive
Course in Medical Ethics, Boundaries, and Professionalism) for physicians
that was designed in consultation with licensure agencies to address the
needs of physicians with problems in the areas of ethics and boundaries.17
The course includes multiple teaching and assessment methods, such as
case discussions, knowledge tests, skills practice, and reflective essays
based on the participant’s ethical lapse. During a seven-year period from
2005 through 2012 the course had 358 participants.
The University of Colorado School of Medicine recently published
results from its comprehensive remediation program18 that is utilized
by medical students, trainees, and attending physicians, with nearly
half of participants being medical students. The remediation program
is available to learners having a variety of deficits, including deficits in
medical knowledge and clinical reasoning and other areas, as well as in
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Medical Professionalism: Best Practices
professionalism. During a six-year period from 2006 through 2012, 151
learners were referred. An analysis of the program showed that the prevalence of professionalism deficits increased as training level increased. Of
note, most learners had more than one deficit. A remediation specialist
conducts a semi-structured intake interview with each participant. A
“Success Team,” comprised of the remediation specialist and learner, and
possibly others (e.g., faculty from the referring clerkship, a mental health
professional, the student affairs dean), reviews the learner’s academic
record, direct observations, and other relevant material, and then creates
and implements a remediation plan to correct the identified deficit. The
plan includes deliberate practice, regular feedback, and an opportunity for
the learner to reflect on his or her performance. Reassessments, assigned
by the Success Team, are performed by faculty members who are unaware
of the learner’s remediation status. They may consist of such things as
end-of-rotation assessments, direct observations, multiple-choice question exams, or standardized patient encounters. The course, clerkship, or
program director receives the results and makes the ultimate determination regarding success of the remediation efforts. Within the University
of Colorado program, poor professionalism was the only predictor of
probationary status. The program reports an overall remediation success rate of ninety percent, with success meaning that referred learners
graduated from their training programs, were in good academic standing,
transferred to another program and graduated, or were practicing medicine without restrictions.
While approaches to unprofessional behavior are similar across the
continuum of practice from medical student to practicing physician, there
are some unique aspects of addressing unprofessionalism at each training
level with regard to the types and spectrum of unprofessional behavior,
the types of resources that are applicable and available for remediation,
and the interventions that are most pertinent to each level of medical
training and practice. Focusing specifically on remediation of medical student professionalism, the Ohio State University College of Medicine professionalism program involves a step-wise approach as described below.
Alleged lapses in professionalism may be brought to the attention of
any member of the Honor and Professionalism Council (HPC) or directly
to the Associate Dean of Student Life. The Associate Dean investigates the
concern in order to further characterize the behavior that has occurred.
The Associate Dean speaks directly with the reporter (faculty member,
resident, or fellow student) and has an exploratory meeting with the accused student to hear his or her viewpoint. Once the Associate Dean determines that the situation merits further evaluation, the case is referred
to the Honor and Professionalism Council.
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4. Review of Current Models for Remediation of Professionalism Lapses
The HPC is comprised of students elected by their class peers, plus a
faculty advisor. The HPC holds quarterly business meetings and ad hoc
hearings. When a student is referred for a professionalism lapse, the HPC
assembles a Hearing Committee. The Hearing Committee is comprised
of student peers, the faculty advisor, and two non-voting faculty members
who contribute input during the hearing. The student meets with the
committee and is permitted to bring one individual (advocate) to speak
on his or her behalf. During the hearing, the accused student has an opportunity to present his perspective to his peers regarding the behavior
that occurred, to provide the context of the situation, and speak to other
relevant details. The members of the Hearing Committee seek input from
the student to verify the concern, to understand the student’s viewpoint,
and to learn of any contributing factors. The HPC student members vote
to determine whether a lapse has occurred. If the vote affirms that a lapse
of professionalism has occurred, the Hearing Committee has an open discussion to formulate a plan of action. The plan is voted on by all members
of the Hearing Committee, with a two-thirds majority vote required to
approve the recommended remediation plan and a higher majority vote
required if the recommendation is for student dismissal. The Associate
Dean meets with the student shortly after the hearing to convey the HPC
findings and remediation plan.
If the Hearing Committee determines that a professionalism lapse has
occurred and that remediation is appropriate, specific interventions and
remediation are recommended that are germane to both the individual
student and the specific lapse to help the student grow and succeed in
his or her professional development. Examples of suggested interventions
include assigning the student a faculty mentor or coach, asking the student
to prepare a written reflection, asking the student to prepare peer education materials, or referring the student to a specific college or university
resource. The Associate Dean of Student Life reviews the HPC remediation plan with the student and implements the plan.
Students who have had a professionalism lapse are followed for any
recurrent lapses. It is rare that students return to the HPC for another
lapse, either similar or dissimilar, during the remainder of their time in
medical school.
Summary and next steps
Several themes emerge from the published literature regarding remediation of professionalism lapses. First, as a medical profession we must
maintain self-accountability and adherence to professionalism standards,
and we must own and address our shortcomings. Assessment of professional behavior and remediation of lapses should be profession-led and
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Medical Professionalism: Best Practices
occur across the continuum of practice from the medical student to the
trainee to the practicing physician. Efforts to assess and guide professional
development need to begin at the earliest stages of medical training.
Remediation programs that address professionalism lapses frequently
take a graduated approach, with the intervention matching the severity of the behavior or the recidivism of the offender. Some remediation
programs are highly individualized, resource-intensive, and time consuming,18 which further underscores the need to establish the most effective
and efficient practices.
Finally, we need evidence- and outcome-based best methods. Having
strategies for remediation of professionalism implies that we are able to
identify individuals who are not competent and that remediation is a successful strategy for correcting deficits in professional behavior. Heretofore,
there has been a paucity of evidence to guide best practices of remediation in medical education at all levels.12 To remedy deficiencies in professionalism, physicians and physicians-to-be may need role models, explicit
instruction, guided practice, and mentored reflection. Outcome measures
that help define the effectiveness of various methods will lead to further
refinement of remediation strategies and perhaps to better specificity of
methods based on type of behaviors or learning level.
In summary, the medical profession and its individual members must
hold itself accountable to standards of competence, ethical values, and interpersonal attributes.2,3 This call for accountability challenges us to better
identify individuals who are not meeting standards of professionalism and
to find the best ways to change their behavior.
References
1. Papadakis MA, Paauw DS, Hafferty FW, et al. Perspective: The education
community must develop best practices informed by evidence-based research to
remediate lapses of professionalism. Acad Med 2012; 87: 1694–98.
2. Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. More than a
list of values and desired behaviors: A foundational understanding of medical
professionalism. Acad Med 2014; 89: 712–14.
3. Leach DC. Transcendent professionalism: Keeping promises and living the
questions. Acad Med 2014; 89: 699–701.
4. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by
the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad
Med 2010; 85: 220–27.
5. Bryden P, Ginsburg S, Kurab, B, Ahmed N. Professing professionalism:
Are we our own worst enemy? Faculty members’ experiences of teaching and
evaluating professionalism in medical education at one school. Acad Med 2010;
85: 1025–34.
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4. Review of Current Models for Remediation of Professionalism Lapses
6. Roff S, Chandratilake M, Mcaleer S, Gibson J. Preliminary benchmarking
of appropriate sanctions for lapses in undergraduate professionalism in the health
professions. Med Teach 2011; 33: 234–38.
7. Zbieranowski I, Takahashi SG, Verma S, Spadafora SM. Remediation
of residents in difficulty: A retrospective 10-year review of the experience of a
postgraduate board of examiners. Acad Med 2013; 88: 111–16.
8. Teherani A, O’Sullivan PS, Lovett M, Hauer KE. Categorization of
unprofessional behaviours identified during administration of and remediation
after a comprehensive clinical performance examination using a validated
professionalism framework. Med Teach 2009; 31: 1007–12.
9. Lucey C, Souba W. Perspective: The problem with the problem of
professionalism. Acad Med 2010; 85: 1018–24.
10. Cohen JJ. Professionalism in medical education, an American perspective:
From evidence to accountability. Med Educ 2006; 40: 607–17.
11. Myers MF, Herb A. Ethical dilemmas in clerkship rotations. Acad Med
2013; 88: 1609–11.
12. Hauer KE, Ciccone A, Henzel TR, 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: 1822–32.
13. Buchanan AO, Stallworth J, Christy C, et al. Professionalism in practice:
Strategies for assessment, remediation, and promotion. Pediatrics 2012; 129:
407–9.
14. van Mook WN, Gorter SL, De Grave WS, et al. Bad apples spoil the barrel:
Addressing unprofessional behaviour. Med Teach 2010; 32: 891–98.
15. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary
approach to promoting professionalism: Identifying, measuring, and addressing
unprofessional behaviors. Acad Med 2007; 82: 1040–48.
16. Brigham and Women’s Hospital. Center for Professionalism and Peer
Support. http://www.brighamandwomens.org/medical_professionals/career/
cpps/. Accessed May 25, 2014.
17. Parran TV Jr., Pisman AR, Youngner SJ, Levine SB. Evolution of a remedial
CME course in professionalism: Addressing learner needs, developing content,
and evaluating outcomes. J Contin Educ Health Prof 2013; 33: 174–79.
18. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic
outcomes of medical students, residents, fellows, and attending physicians
referred to a remediation program, 2006–2012. Acad Med 2014; 89: 352–58.
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Chapter 5
Cultural Transformation in Professionalism
Jo Shapiro, MD
T
he Center for Professionalism and Peer Support (CPPS) at the
Brigham and Women’s Hospital (BWH) was founded in 2008,
growing out of a sense that a cultural shift within medicine was
needed. We were seeing more and more over-worked, stressed physicians
facing a steady increase of responsibilities and expectations, often without
the resources to support them. We first formulated the Center’s mission:
to encourage an institutional culture that values and promotes mutual
respect, trust, and teamwork. We then developed several core initiatives
to support our mission. These include: peer support following adverse
events, unanticipated outcomes, or other emotionally stressful events
such as caring for trauma victims; disclosure coaching; defendant support;
teamwork and effective communication training; wellness programs; and
a professionalism initiative. Our professionalism initiative1 is the focus of
this chapter. We feel strongly, however, that the support and training offered through all of our programs is central to enhancing a supportive and
cohesive professional culture within our institution.
Changing institutional culture is a lofty goal. We approach this challenge with the understanding that the culture of an institution is something that we define and redefine every day. It is not primarily about what
is written in a policy or a code of conduct. While those things can be vitally important, we recognize that the culture of our workplaces is organic
and is expressed daily though our actions and values. To make meaningful
culture change we need to be present and active with both support for and
education around professional behavior.
Professionalism education and training
We define professionalism as behavior that helps build trustworthy relationships. This means all relationships—between a clinician and patient,
a physician and nurse, any health care team member and a student—are
important.
In building our professionalism initiative, we understood the importance of setting expectations as well as providing education and training. In order to raise awareness about behavioral expectations as well
as about our training and support efforts, every physician at BWH from
intern through senior faculty is required to participate in our interactive
simulation-based professionalism training sessions. We partnered with
Employment Learning Innovations (ELI), an employment law company,
to design the curriculum using video scenarios with an accompanying
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Medical Professionalism: Best Practices
workbook.
One of the video vignettes features Dr. Mills—a well meaning (we
assume) surgeon who finds himself significantly under-resourced. We
have all had moments when we feel highly stressed for multiple possible
reasons such as having to be in two places at once, feeling as if those
around us are under-performing, needing lab results that are unavailable,
or not having access to important patient information. This is where Dr.
Mills finds himself, and he behaves in a way that seems completely inexcusable and horrendous. During the session participants identify the
disruptive behaviors being exhibited—what specifically Dr. Mills did that
was unprofessional—and we talk about how he could have handled the
situation differently. In addition, we role play giving Dr. Mills feedback
about his behavior. In facilitating these discussions we acknowledge that
it’s very easy to sit in any training session and believe that we ourselves
would never behave in this unprofessional way; we point out that most
of us are, in fact, capable of this kind of behavior. Given a situation with
stressors such as poor resources, sleep deprivation, or overwhelming
responsibility, most of us are at risk of behaving somewhat—or even
completely—unprofessionally.
These professionalism sessions are just the beginning of an institutional
conversation. Our Center has other resources for ongoing professional
development, such as training in conflict and stress management as well
as workshops to help clinicians develop skills in giving feedback.
In addition, we emphasize that when interacting with a colleague who
is exhibiting disruptive behavior, there are other options beyond reporting the behavior. Ideally, we’d like to be training people to address bad
behavior when they see it—to have a clear and respectful conversation
with the person about the behavior at issue. Yet we recognize that in a
hierarchical environment it will not always be or feel safe to have these
direct conversations; we therefore must have a process in which people
can come forward and voice their concerns. While our institution has a
hierarchy of responsibility, we do not have a hierarchy of respect: we are
all equal when it comes to deserving respect.
Handling professionalism concerns
We cannot expect people to behave respectfully or feel supported in
a culture that does not hold people accountable for their behavior. If
anyone has a concern about a physician’s unprofessional behavior at our
institution—the person with the concern (the reporter) can be a student,
nurse, secretary, faculty member—that person can address the concern
through the Center. We first meet with the reporter to listen, discuss, and
decide together on a plan. One of our guiding principles in handling these
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5. Cultural Transformation in Professionalism
concerns includes being as discreet and respectful as possible to everyone,
including the person about whom the concerns are reported (the focus
person).
As a next step we generally like to speak with other people who work
with the focus person, and we make sure that the reporter is comfortable
with our doing that. We explain that this inquiry is not a 360° evaluation—this is a very important point. We are specifically investigating
one aspect of someone’s professional behavior. If the reporter agrees, we
solicit the names of people he or she recommends, and we then perform
multisource interviews. We assure the reporter and the people we contact subsequently that we have a safe system that focuses on the specific
problematic behavior. We gather data and then bring this information to
the focus person’s supervisory physician, such as a chief or chair, to get
his or her perspective.
How the supervisor responds is variable and determines our next
steps. Sometimes he or she is well aware of the problem but has not taken
any action to remediate it. Generally the supervisor does not know how
to address the problem. It stands to reason that supervisors have had
trouble giving the focus person feedback in the past, as few leaders have
had training in giving difficult feedback. We then agree on a plan that
generally involves our meeting with the focus person together. This meeting accomplishes two things. First, it provides on-the-job training for the
chair or chief to see how to conduct these difficult feedback conversations.
Second, the focus person responds differently when his or her supervisor
is there to support the importance of having this conversation and of holding the person accountable for his or her behavior. A critical point that we
stress in this conversation is the unacceptability of any retaliatory behavior
on the part of the focus person.
We have developed an algorithm for giving frame-based feedback2 that
provides the basic format for this meeting with the focus person. First we
state the specific types of behavioral concerns. It is important to remind
the focus person that this is not a performance evaluation. We are not
suggesting that this problematic behavior is all that defines the person’s
career. After clearly stating the specific problematic behaviors and why
they are concerning, the second step of the algorithm is to elicit the focus
person’s frame—how she or he understands the problem. The third step
of the algorithm is to match the discussion to the focus person’s frame.
The central tenet of this feedback technique involves using the principles of autonomy support—having the person tap into his or her intrinsic
motivation to change behavior. We may try to draw out the focus person’s
empathy by saying something like: “This is how many people feel when
they work with you. Did you know that this is the impact your actions
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Medical Professionalism: Best Practices
have on your team?” Sometimes this leads to a discussion of systems issues
that the person feels are contributing to his or her behavior patterns. We
communicate clearly that we do understand the difficulties, but that these
do not obviate personal accountability for the behavior. This is not to say
that systems issues are not real or contributory, and we do not ignore
them when they are. We have to be willing to advocate for people in addressing systems changes, but at the same time people need to understand
that they still must behave respectfully despite real situational challenges.
The focus person might, alternatively, frame his or her angry or disparaging behavior as trying to get better patient care. In fact one of the
most frequent reactions to a discussion of unprofessional behavior is: “I
am a patient advocate and I need to behave this way in order to protect
my patient.” We respond to this by explaining that we understand and
respect that commitment to patient care, and we recognize the person’s
reputation for being a patient advocate. We point out that what the person
likely doesn’t realize is the correlation between unprofessional behavior,
problematic teamwork communication, and negative patient outcomes.
We explain that the individual’s behavior actually puts patients at risk; that
this is a safety issue. We explore the fact that the impact of that negative
behavior is in direct opposition to the person’s intent. This is an example
of how we match the discussion to the focus person’s frame as a way to
encourage intrinsic motivation for behavior change.
Another example of matching the discussion to the focus person’s
frame is when the behavior in question involves sexual harassment.
Sometimes the person’s response is defensive, denying responsibility. For
example, the focus person might explain why the behavior has nothing to
do with him or her; he or she explains that it is really about someone trying to retaliate for an unfairly perceived slight. We respond by explaining
that regardless of why the person thinks the behavior was reported, the
important point is that the behavior can never happen again. We will then
send the focus person to outside counsel for a discussion of the extensive
legal trouble that can result if the behavior continues. This approach generally motivates behavior change.
With this same complaint, a different response we may see is embarrassment and apology. The person thought he was being friendly; his
frame might be that he was simply making a clumsy attempt at connecting
with a colleague. Yet upon reflection, he understands why the behavior
is unacceptable. Our response to this frame is quite different from our
response to the person who does not accept responsibility. To this person
we explain that while we do understand his intent, the behavior made a
colleague very uncomfortable. This level of discussion and intervention is
generally enough to correct the problem; outside counsel is used just to
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5. Cultural Transformation in Professionalism
reinforce the legal ramifications.
One challenge in giving difficult feedback is the unpredictability of
people’s reactions and the reality that we cannot control these reactions.
The challenge is to work with whatever comes up and be flexible in the
response, depending on the focus person’s frame. Our process is therefore both generally consistent and completely personal, depending on the
person’s frame and reactions to the feedback. In responding, we also must
take into account how egregious the behavior is and how long it has been
going on.
These examples demonstrate that we hear a somewhat familiar pattern
of responses from people when giving feedback. Regardless of whether the
focus person has personal insight, our job is to explain that that person
must change his or her behavior if he or she wants to stay at our institution. This must be the bottom line. The person does not have to agree; our
job then becomes managing people who do not recognize the importance
of changing their behavior.
Most importantly, we all must be held equally accountable. Not holding
everyone to the same behavioral expectations allows for a double standard
that can be more damaging than doing nothing at all. Our accountability
process is, among other things, designed to address egregious or repetitive
unprofessional behavior. Without remediating this kind of behavior we
cannot take our work to the next level—working to promote healthy team
dynamics and helping individuals communicate effectively with one another. The reality is that there simply are some workplace bullies—people
who do not respond to feedback and do not recognize the destructive
effects of their own behaviors. These people—a small minority—tend to
only respond and begin to change when they are threatened with external consequences such as losing their positions. When presented with
the need to change their behavior some people refuse to accept personal
responsibility; they respond with denial, anger, and threats that can be
extremely demoralizing and damaging to an institution’s professional culture. This is why our process must account for both types of individuals.
In order to feel confident that our program could manage the full spectrum of problematic behavior it was, and still remains, critical that we
have the unwavering support and backing of our institutional leadership.
Dr. Gary Gottlieb, BWH President at the time of the Center’s founding, as
well as our current President, Dr. Elizabeth Nabel, have been unequivocal
in their commitment to stand behind our work.
Our work with the focus person is entirely behavior-based. We have
learned not to go down the rabbit hole of trying too hard to understand
the potential reasons for the person’s behavior. For example, we do not
explore the possibility that the person has a personality disorder or should
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Medical Professionalism: Best Practices
be evaluated. We found, early on in this work, that this approach resulted
in significant distraction from the real issue at hand, and we found ourselves over-referring in an attempt to diagnose the reason behind the
behavior. As a result, we have shifted toward a focus on the behavior itself
and away from attempting to diagnose. This is not to say that we don’t
offer people resources, because we do. And if we find that someone is
impaired, this is a different matter: in these cases we are very quick to refer them to Physician Health Services, an outside professional group that
evaluates physicians for impairment. But we are much more frequently
called in to address repetitive unprofessional behaviors without an obvious underlying behavioral health issue.
Another area of caution, in addition to being careful not to “treat” the
focus person as we might a patient, is the concept of cultural relativism.
People sometimes point to cultural excuses or explanations for their unprofessional behavior. Our response is quite clear—it’s not relevant that
this behavior is tolerated elsewhere; you cannot behave that way here. We
describe the problematic behavior to the focus person, explain that the behavior needs to stop, and describe the behavior we expect going forward.
One of the biggest barriers we face in this work is, interestingly, too
high a tolerance on the part of supervisory physicians. They may be overly
concerned about the focus person’s career; all they can see is a colleague
whom they hired and have devoted considerable time and energy into
helping develop. As a result, there are times when we at CPPS are “holding” all of the damage and sadness that results from this bad behavior. Our
role at that point is to help the supervisor understand the degree of destruction caused by the unprofessional behavior. In this way, the suffering
of those people impacted by the unprofessional behavior is made visible to
the leadership. We do this with the important support of our chief medical officer (CMO) Stan Ashley, MD, as well as our legal counsel for the
hospital, Joan Stoddard. Sometimes in particularly intractable situations
it can make all the difference to have the CMO in the room to support
our process. We have also formed a professionalism advisory committee
that meets quarterly to review cases. At the end of the day, this cultural
transformation can only happen with strong institutional support.
Outcomes
Since 2009 we have had 270 individual physicians about whom concerns
were raised (and there may have been more than one concern per person)
and ten instances of our assisting with team dysfunction. We categorize
the problematic behavior broadly as follows: demeaning, angry, uncollegial,
shirking responsibilities, hypercritical, unprofessional patient communications, clinical dyscompetence, misconduct, and sexual harassment.
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5. Cultural Transformation in Professionalism
One of the central tenets of this process, and what makes it functional
and useful, is that we all must be held accountable. Our goal is not to get
rid of people; our goal is to motivate them to change their behavior. Yet we
must, at the same time, demonstrate the accountability of this process in
our insistence that physicians with repeated and egregious unprofessional
behavior cannot remain at BWH. Since 2009, twenty-five physicians have
left BWH due to professionalism concerns, and six were demoted from
positions of authority.
Support programs
We recognize that while holding each other accountable, we also need
to support one another. People perform best in a supportive environment.
We therefore have developed programs in which we have physician and
nurse peers reach out to clinicians in times of emotional distress, such as
being involved in an adverse event or when facing a lawsuit. The trained
peers are there to listen, empathize, and offer suggestions for healing and
recovery. One study we performed showed that ninety percent of physicians wanted to talk to a physician colleague, not a mental health professional, after an adverse event.3 If a physician needs to make a disclosure
to a patient, we have disclosure coaches who work with risk management
to help the physician prepare to have compassionate and transparent
conversations with the patient and family, and who also understand the
emotional challenges facing the physician.
Conclusion
In this context of supporting and being there for each other, we believe that our professionalism initiative and other support programs are
all necessary and beneficial elements of the positive change we seek to
make within the institution. Culture is manifested by how we speak to
each other, our ability to encourage staff to speak up when someone is
not behaving well, and what we do to support one another. Our support
and accountability programs demonstrate that the institution values and
respects its employees. I will end with a quote from Vaclav Havel about
hope, which he believes is “not the conviction that something will turn out
well, but the certainty that something makes sense, regardless of how it
turns out. The hope of fellowship, and kindness, and service.”
Acknowledgment
I would like to thank Pamela Galowitz for her invaluable help in editing this chapter.
References
1. Shapiro J, Whittemore AW, Tsen LC. Instituting a culture of professionalism:
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Medical Professionalism: Best Practices
The establishment of a center for professionalism and peer support. Jt Comm J
Qual Patient Saf 2014; 40: 168–77.
2. Rudolph J, Raemer D, Shapiro J. We know what they did wrong, but not
why: The case for “frame-based” feedback. Clin Teach 2013; 10: 186–89.
3. Hu YY, Fix ML. Hevelone ND, Lipsitz SR, et al. Physicians’ needs in coping
with emotional stressors: The case for peer support. Arch Surg 2012; 147: 212–17.
66
Chapter 6
Enhancing Interprofessional
Professionalism: A Systems Approach
Rebecca Saavedra, EdD
T
he University of Texas Medical Branch (UTMB) has a long-standing
commitment to promoting interprofessional professionalism (IPP).
A 2007 Academic Medicine article, “The Journey to Creating a
Campus-Wide Culture of Professionalism,” 1 described our philosophy,
definitions, and initiatives to instill professionalism that began over a decade before. Since then our professionalism endeavors and understanding
of interprofessionalism have continued to evolve. Today we recognize the
significance of IPP as a strategic priority and component of not only our
institution’s success but key to better integrated care outcomes. This paper
bridges what was initially undertaken as a campus-wide interdisciplinary
professionalism effort with our current understanding and emphasis on
interprofessional practice.
UTMB’s campus-wide approach to interdisciplinary collaboration
was undertaken to link all members of the university community to the
principles and behaviors focused on patient-, family-, and client-centered
care. Today’s brave new world of health care is altering practice and
relationships so significantly that in the near term academic health centers (AHCs) will need to have fully transformed into new collaborative
partnerships among practitioners, patients, and their families. The “core
of professionalism” involves “those attitudes and behaviors that serve to
maintain patient interest above physician self-interest.” 2 These principles
remain fundamental and timeless but with a freshly imbued sense of urgency and inclusiveness.
Once the concern was that the coming changes in the health care delivery system would “reduce the status of patients to commodities” and
“have a negative impact on the professional behavior of physicians.” 2
Today we understand that AHCs must address environmental challenges
that require integrated care models, better outcomes, lower costs, and enhanced patient satisfaction. The emphasis on new models of care relies on
collaborative effective interprofessional teams as a strategic foundation to
achieve a patient-centered organization that fully engages patients in their
care. IPP is no longer an ideal; it is a pragmatic reality.
Over the past almost two decades, UTMB has established a systematic
mix of programs—clinical- and academic-based—to meet the new challenges and adapt in a dynamic health care environment. UTMB’s systems
approach instills a focus on action to promote interprofessionalism across
the institution for students, faculty, and employees. These processes are
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Medical Professionalism: Best Practices
aimed at understanding, influencing, monitoring, and adjusting our efforts based on experience and lessons learned to accelerate our progress
toward a more interdependent professional environment. This approach
builds in opportunities for dialogue, evaluation, and improvement, thus
allowing for organizational transformation. The organizational vision is
set by executive leadership whose actions demonstrate their commitment
and systematic focus on professionalism as a standard of conduct for
everyone at UTMB. As the UTMB Professionalism Charter states: “The
foundation for UTMB’s culture of professionalism is rooted in the trust
placed in those who deliver patient care, conduct research, educate future
health care professionals, provide administrative support, maintain a supportive environment and strive to learn.” 3
The transformation begins
Establishing a culture of IPP can only succeed if there is critical leadership sponsorship and an infrastructure in place to ensure that policies
and systems support skilled practitioners who work respectfully and collaboratively in effective teams. The UTMB Professionalism initiative has
been in place continuously since 1998, spanning two university presidencies to the present. UTMB Presidential sponsorship is indispensable in
not only guaranteeing necessary resources but also in elevating activities
to institutional prominence.
Additional strategic partnerships have been forged with the Provost/
Dean of Medicine; Deans of Health Professions, Nursing and Graduate
Schools; CEO of the Health System; and the Executive Vice President
of Business and Finance. These individuals serve as members of the
President’s Executive Committee and set the tone of collaboration and
respect across the institution. The Executive Committee is a critical ally in
crafting and delivering the message to the various segments of the campus
community.
Over time, UTMB has established a matrix of institutional programs,
initiatives, and monitoring systems to create a focus on action and engagement by the campus community to form a collegial and patient-centered
environment. Early on, discussion forums were held to define and reflect
on the concept’s meaning across disciplines. Meetings with department
chairs, faculty senate, and student senate were a part of a “listening tour”
to determine the readiness of the campus culture to adopt a multidisciplinary perspective. The outcome underscored that what unites the
education, research, and patient care missions of the organization is a
patient-centered focus and that professionalism is a collective obligation.
In the beginning, the university’s IPP philosophy was not embraced by
all members of the campus community. Bridging differences and rejecting
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6. Enhancing Interprofessional Profesionalism: A Systems Approach
an entitlement mentality were essential to merge individual and discipline
expertise into a common multidisciplinary understanding. The strategy
focused on the mutual goal of improved treatment outcomes and patient
care, de-emphasizing competition and accentuating a shared vision of
high functioning teams.
The professionalism committee instrument for change
In 1998 the UTMB Professionalism Board was formed to develop a
multidisciplinary approach to advancing professionalism, recognizing that
a fundamental concern for the patient should characterize all members of
the AHC community. The Board’s charge was to launch a comprehensive
set of professionalism initiatives throughout the institution and to transform the culture of health care training and practice.
The Board has evolved over time to become the Professionalism
Committee, and has played a central role in executing and linking key
professionalism initiatives. It has met continuously since 1998, proactively
addressing campus issues and changes in the health care delivery system
that impact professional behavior and the healing environment. The
Committee regularly monitors results of institutional climate surveys, and
meets with the President, Provost, Deans, and Student Government to
proactively address ethical challenges and provide recommendations and
seek action as needed.
Membership continues to include individuals from across the mission
areas and workforce segments (e.g., academic and health system administration, physicians, nurses, faculty, and students from all four UTMB
schools). The broad representation ensures that messages can be tailored
to suit respective points of view. Members are appointed by the President
and have demonstrated a commitment to professionalism and, because of
each member’s specific role, serve as knowledgeable and effective change
agents.
Given the diversity and breadth of roles, the committee is able to address matters related to IPP across the enterprise and to recommend and
influence solutions in the academic and clinical arena. Four of its members have attended the highly recognized Vanderbilt University Disruptive
Behavior Conference and provide valued insight and direction. In addition, UTMB has within its ranks recognized leaders in the field of professionalism, professional identity formation, and bioethics. These experts
provide invaluable guidance to the institution and committee.
Putting the charter into practice
Starting in 2000 a series of university programs were developed to
build awareness about exemplary models of professional behavior. These
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Medical Professionalism: Best Practices
included: Going the Extra Mile, a campus-wide program for staff, students, and faculty to recognize outstanding professional qualities of their
peers; the John P. McGovern Academy of Oslerian Medicine, which endows School of Medicine faculty who exemplify ideals of professionalism
and humanism; and You Count employee surveys to solicit perceptions
about workforce culture.
In 2002, the effort to define professionalism on campus gained momentum with the publication of the Physician Charter in the Annals
of Internal Medicine4 and Lancet,5 which identified and defined the
principles and commitments of professionalism. With a grant from the
American Board of Internal Medicine, UTMB began to explore the
Physician Charter’s application to the university. The result is the UTMB
Professionalism Charter,3 which extends the professionalism themes and
standards of conduct to everyone at UTMB—faculty, staff, and students.
The university’s position was pioneering and has proven to be an important strategy to address the critical success factors in today’s academic
health systems. Health care’s future is systems-based and embraces teambased practice to improve clinical outcomes and effective care coordination. The core of these relationships is interprofessionalism, focused on
greater collaboration, respect, and effective communication.
The UTMB Charter was written with this integrative model in mind
to encompass the campus as a whole, recognizing that all members of the
AHC community share equal responsibility for its professional commitments, “from the clinician who ensures quality care, to the staff member
who ensures confidentiality of patient records.” 1 The Charter’s mandate
therefore is to hold every member of the UTMB community accountable
for acting with integrity, compassion and respect towards one another and
those we serve. 3
The UTMB Professionalism Charter is a living document that is
regularly reviewed and updated. The Charter serves as a capstone for all
discipline-specific standards and codes of conduct. It is a unifying set of
beliefs and behaviors that are professed to the community. The ten commitments have been written so that a “line of sight” is meaningful from
wherever in the institution one stands or whatever role one has. “Everyone
who works or studies at the University of Texas Medical Branch is a member of a community of professionals dedicated to advancing UTMB’s mission, vision and values.” 3 The Professionalism Charter is utilized in our
orientation and leadership programs. All fundamental efforts to improve
the capability and capacity of our workforce are inextricably linked to the
standards outlined in the Charter.
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6. Enhancing Interprofessional Profesionalism: A Systems Approach
The Charter’s main objective is to build strong understanding and
consensus, while generating a culture that allows and encourages dialogue
that is both candid and meaningful.
UTMB Professionalism Charter Commitments
1. Commitment to a culture of trust
2. Commitment to diversity
3. Commitment to competence and growth
4. Commitment to confidentiality
5. Commitment to honesty
6. Commitment to the responsible use of resources
7. Commitment to value
8. Commitment to appropriate relations
9. Commitment to manage conflicts of interest
10. Commitment to the appropriate discovery and use of knowledge
Honor pledge
While the UTMB Charter was being developed another IPP endeavor
was occurring across campus. It is important to acknowledge the role students played in the progression of IPP at UTMB. Their passion, compassion, and altruism were a source of vitality to the movement. It began with
efforts of the Medical School Student Honor Education Council, which
saw a need to educate and address academic integrity issues that were
driven from students’ perspective and yet complementary to institutional
efforts. The students’ close association with other health professions student organizations quickly resulted in IPP becoming a multidisciplinary
effort and the development of a four-school unifying statement of IPP.
On my honor, as a member of the UTMB community, I pledge to act with integrity,
compassion, and respect in all my academic and professionalism endeavors.
Each word was deliberated at length, with students and faculty reflecting on the values that are inherent in the various codes of conduct
and standards of the health professions. The honor pledge encapsulates
the key values of IPP. It is a measure of the professional and academic
evaluation of students in all courses and complements the UTMB Student
Conduct and Discipline Policy.
Honor pledge plaques and signs are displayed throughout UTMB, serving as a reminder of the basic principles. The pledge is introduced to new
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Medical Professionalism: Best Practices
students at the All School Orientation and New Student Welcome events,
which themselves are examples of UTMB’s interprofessional tradition.
The orientation includes new students from each of the four schools
and includes a Welcome Weekend of team building and networking activities. The program is a collaborative university event that is hosted by passionate volunteers of second-year students from all four schools, faculty,
and staff who serve as facilitators and staff. The All School Orientation
and Welcome Weekend showcase UTMB values and mission and set expectations that students are members of a diverse community of professionals who share a common set of professional values.
Becoming a professional
UTMB also has augmented student development activities with formal course work to engrain professionalism and interprofessionalism
throughout the curriculum of the four schools. For example, the Graduate
School of Biomedical Sciences convenes an annual seminar on ethics of
scientific research, the School of Nursing has classes on ethical practice
and cultural sensitivity, and the School of Health Professions and School
of Medicine (SOM) have embedded professionalism in the students’ training and curriculum.
In 2005, the SOM introduced professionalism with five longitudinal
themes across the medical curriculum to ensure broad integration with
medical training. During the first and second years, the practice of medicine course6 engages students in small group discussions about health care
delivery, interprofessional teamwork, and ethical practice. The sessions
encourage opportunities for reflective growth. The faculty continues to
seek opportunities to enhance the professionalism themes within existing
and new classes, programs, and activities.
UTMB has implemented an Interprofessional Education program
with courses open to all students for credit. These include: Foundations
in Patient Safety and Health Care Quality; Spirituality and Clinical Care;
and Global Health Interprofessional Core Course. An Interprofessional
Pediatric Advocacy Program is designed to have students work in interprofessional teams with Child Protective Services caseworkers and families. Pediatric End-of-Life Simulation brings students together from all of
the schools to participate in a high-fidelity simulation focused on the care
of an infant and family as a child faces cardiopulmonary arrest. Annually,
UTMB hosts Interprofessional Education Day, which features a keynote
speaker and a series of simulation workshops involving interprofessional
teams of students with a trained facilitator.
UTMB has augmented the curriculum with experiential opportunities
for interprofessional teamwork through intentional student community
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6. Enhancing Interprofessional Profesionalism: A Systems Approach
service learning projects.7 Frontera de Salud and St. Vincent’s Free Clinic
are student-run community service projects that were founded and
staffed by medicine, nursing, and health professions students to provide
community-based health programs. Both student organizations promote
opportunities for our students to work with interprofessional teams. Our
students’ evaluations of these experiences continue to be positive year
after year.
“Do as you say, not as you do”
Jordan Cohen, president emeritus of the Association of American
Medical Colleges states, “Unless we convert our learning environments
from crucibles of cynicism into cradles of professionalism, no amount
of effort in the admission arena is going to suffice.” 8 Bullying behavior is
inimical to interprofessional professionalism. Verbal and physical harassment and intimidation are unfortunate standard examples of mistreatment
endured by health care learners operating through informal clinical and
classroom interactions forming what is known as the hidden curriculum.9
On July 9, 2008, the Joint Commission published the Sentinel Event Alert,
Issue 40, that declares, “Intimidating and disruptive behaviors can foster
medical errors, contribute to poor patient satisfaction and to preventable
adverse outcomes, increase the cost of care and cause qualified clinicians,
administrators and managers to seek new positions in more professional
environments.” 10
UTMB is committed to providing the best educational climate possible
and recognizes the need to safeguard students who may be the victims of
or witnesses to unprofessional and disruptive behavior by faculty. The inherent vulnerability of students and their dread of reprisal may leave them
reluctant to protest such behavior. In 2004, UTMB introduced an online
mechanism for students to report unprofessional behavior or mistreatment—whether from a resident, faculty member, fellow student, or staff.
The Professionalism Concern Report (PCR) is located prominently
on the UTMB Professionalism website and allows students from all four
schools to bring forward professionalism concerns to a neutral third party.
The forms can be submitted anonymously by students; they may also meet
with the Student Ombudsman or other officials as an option. The PCR is
triaged by the co-chairs of the Professionalism Committee (a SOM faculty
and a university administrator) and sent to the appropriate department
chair/manager to resolve the student concern.
Examples of unprofessional behaviors reported include: verbal abuse,
public belittlement, disparaging comments by faculty or other health care
team members, discourtesy in the classroom by fellow students, or student
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Medical Professionalism: Best Practices
cheating. The administrator is asked to address the issue by following up
with the faculty, student, or employee within his or her department.
The action begins by a determination of what events can be validated.
A conversation with the faculty or staff member is convened and then
appropriate action is taken. The action might be as modest as a brief conversation and a verbal reminder of appropriate standards of conduct and
behavior. With serious findings a more directive action plan might be the
outcome. The intention of this process is to remind and remediate. Faculty
and other members of the UTMB community have a responsibility to be
accountable to one another and immediately address lapses in behavior
and support the remediation of problems. Being accountable constitutes
the essence of professional behavior.
Remediating student professionalism
Campus-wide remediation and intervention mechanisms have been
introduced to address student professionalism. At UTMB, faculty and
staff have an opportunity to assess student professionalism as a part of
students’ academic evaluation across the four years. If faculty or staff
observe behavior that is inappropriate by a student they may submit an
Early Concern Note (ECN) for follow up action. The ECN is an informal
intervention process that is separate from the academic record.
“ [ECN] is a part of a campus wide initiative to heighten awareness of
the importance of professionalism behavior.” 11 It remains confidential
between the student and the Associate Dean, unless and until a student
receives three or more ECNs during matriculation. It is not anonymous
and students receive a copy of the report as a part of the mentoring and
guidance process. Some student behaviors, such as academic dishonesty
and unlawful behavior, are not a part of this process and are administered
through the Student Affairs office as a part of the University Conduct and
Discipline Policy. The ECN is not punitive, but allows for unprofessional
actions to be addressed quickly and may reveal patterns of behaviors that
could advance to truly significant concerns over time.
Monitoring climate
Because UTMB undertook its professionalism initiative enterprisewide to ensure an interdisciplinary approach, the initiative has utilized
multiple modalities to promote and measure its program effectiveness.
UTMB conducts a series of student, employee, and patient surveys to
measure effectiveness of programs and activities that enable a professional environment. The student survey contains a series of questions
that asks respondents to reflect and assess the institution’s commitment
to professionalism and interprofessionalism, to faculty’s commitment
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6. Enhancing Interprofessional Profesionalism: A Systems Approach
to maintaining respectful professional relationships, and to the extent
to which one has observed faculty and students modeling the Charter
commitments.
Student satisfaction scores (from all schools) over three years (2011
through 2013) have overall sustained high marks, with recent slightly
negative declines in some areas. For example, after several years (2002
through 2007) of positive gains, in 2007 96 of students rated professionalism as a priority at UTMB; in 2013, 95 of students from all four schools
reported that professionalism is a priority at UTMB. In 2007, 93 students
reported that they had been treated with courtesy and respect by faculty.
In 2011, 92 of students reported that they had been treated with courtesy
and respect by faculty; in 2013, the rate revealed a small decline to 89.
The scores also decline slightly when the students are asked to assess
their cohort’s professionalism. In 2011, 86 all students reported that students are courteous and respectful in the classroom; in 2013, it had fallen
slightly to 83. In 2011, 89 students indicated that “cheating is not a
problem at UTMB”; in 2013 the score had changed to 87. Survey written
responses and forums with students and faculty have identified environmental, demographic, and technological disruptors that have provoked
adverse outcomes.
In 2011, UTMB began to survey students about their interprofessionalism experiences. In 2011, 79 of all students reported “While at UTMB I
have developed an appreciation for the value of inter-professional teamwork”; in 2013, it has risen slightly to 81. The same holds true for “While
at UTMB, I have learned about the role of different health care professions” (2011 82; 2013 83) and “I have had an opportunity to participate
in inter-professional activities” (2011 77; 2013 86).
UTMB conducts an employee satisfaction survey regularly to measure
workforce climate. The survey asks employees to assess “The person I
report to treats me with respect” and “UTMB treats employees with respect. In 2011 using a Likert scale of 1 = strongly disagree to 5 = strongly
agree, the responses were 4.25 and 3.72 respectively; in 2012, 4.23 and 3.70
respectively, and in 2013, 4.22 and 3.67 respectively. These responses have
trended down slightly.
Monitoring and measuring professionalism and interprofessionalism outcomes are crucial to understanding institutional performance
and avenues of improvement. Results from various student, patient, and
workforce surveys indicate that progress continues to be made, but that
we have not achieved our objective. Senior leaders utilize survey and
quality data to initiate two-way communication, reinforce behavior, and
improve performance. A focus on behavioral aspects of performance and
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Medical Professionalism: Best Practices
interpersonal relationships complements institutional quality initiatives
and strategic objectives.
Advancing IPP during a stable environment is problematic; attempting
to improve interprofessional collaboration, communication, and respect
during turbulent financial and environmental conditions is even more
difficult. Health care reform, financial challenges, consumerism, and
value-based purchasing are just a few of the changing environmental
forces impacting education, research, and health care. Reviewing survey
results allows us to gauge our success, improve our knowledge, and address opportunities for continuous improvement. The slight downturn in
performance has resulted in the organization developing action plans, deploying additional targeted “pulse surveys,” and increased communication
between learners and faculty and employees and managers to determine
the root cause of issues. UTMB is approaching the challenge as an opportunity to role model transparency and collaboration among its leaders.
The assessment tools enumerated above reflect only a small part of
UTMB’s effort to measure the impact of professionalism and interprofessional activities. UTMB is committed to maintaining high standards of
excellence, integrity, and accountability, whether it involves academic or
research activities, clinical practice, or institutional decision-making by
faculty and employees.
Promoting professionalism
UTMB hosts a Professionalism Summit biennially to address the pedagogy of professionalism and the importance of addressing unprofessional
behaviors. The speakers list is a who’s who in the field of professionalism.
In 2004, Maxine Papadakis, MD, lectured on the association between unprofessional behavior among medical students and subsequent disciplinary
action by state medical boards.12 Her pioneering work was foundational
in UTMB’s development of the Early Concern Note process. In 2009,
David Leach, MD, presented on “Creating a Culture of Professionalism:
Reconnecting Soul and Role. In 2011 and 2012, Gerald Hickson, MD,
presented “A Complementary Approach to Professionalism: Identifying,
Measuring and Addressing Unprofessional Behaviors” and “Dealing with
Behaviors that Undermine a Culture of Safety.” Dr. Hickson’s presentations
engaged clinical chairs and health system leadership in a critical dialogue
on the importance of proactively addressing disruptive behaviors.13 In
2014, Barbara Balik, RN, MS, PhD, delivered “Interprofessionalism—Why
Bother?” Dr. Balik’s session emphasized the impact and attributes of a high
functioning team.
These presentations were instrumental in guiding and informing our
journey and provided an opportunity to listen and interact with innovative
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6. Enhancing Interprofessional Profesionalism: A Systems Approach
national experts in the field. The insights gained ignited candid debates
about the hidden curriculum, self-regulation, and the strategic challenges
AHCs are facing. Annually UTMB hosts either the biennial Summit or
informal “brown bag” workshops. These events are powerful reminders
about our responsibility as role models and about the obligation to speak
out and engage those who act unprofessionally.
Interprofessional professionalism as a strategic objective
Professionalism is recognized as critical to the organization’s future
success. The Professionalism Charter’s mandate to “hold every member of
the UTMB community accountable for acting with integrity, compassion
and respect toward one another and those we serve” is one of the institutional strategic goals. UTMB has deployed systematic approaches to
develop and assess workforce engagement and climate. High performance
is characterized by effective communication, patient/client/student focus,
knowledge, skills, and respectful behaviors. Transforming our internal
relationships requires proactive intentional processes put in place to reinforce professional values and ethical business practices.
IPP is more than a theoretical concept or an ideal; it is a strategic imperative and core competency of today’s AHC. Societal, economic, and
technological innovations are disrupting not only traditional hierarchical
structures and relationships among health professionals, but the relationships between provider and patient as well. Innovative training and IPP
education can provide health professionals with opportunities to gain the
skills, knowledge, attitudes, and behaviors needed to fully participate in
integrative health care delivery systems.
UTMB’s model for interprofessional professionalism
Promoting IPP is a multifaceted endeavor and requires a supportive
infrastructure, leadership engagement, and strategic foresight to recognize the fundamental pressures effecting change at AHCs. It requires a
matrix of policies, processes, and individuals committed to addressing
unprofessional behaviors that negatively impact the team’s performance
and patient outcomes. Significantly, it requires the passion and cooperation of faculty members who serve on the front line as health providers,
colleagues, and teachers. As Hickson and colleagues note, “Every physician needs skills for conducting informal interventions with peers.” 13 It
is critical that faculty, residents, and senior leaders provide appropriate
models of respect and inspire each other to act with integrity, compassion, and respect. Role models must be recognized, nurtured, and valued.
UTMB has implemented a comprehensive program to sustain professional behavior and enhance interprofessionalism. Strong leadership focus
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Medical Professionalism: Best Practices
and a systems approach have shaped a culture of shared values and interdisciplinary collaboration at UTMB for fifteen years. The professionalism
initiative is still on course with critical lessons learned and continued
emphasis on sustaining an interprofessional professionalism culture:
1. A reporting mechanism and clear policies are important to support the vulnerable members of the community and hold the individuals
accountable.
2. A vigilant effort is needed that promotes and continually reminds
community members of the values and behaviors that are shared by all.
3. Leadership and management training is necessary to provide skills
to address poor performance and disruptive behaviors.
4. Annual performance evaluation and satisfaction surveys must be
deployed and results measured to effect change.
5. Recognition that professionalism is a strategic objective that is
foundational; it signifies the importance of civility and respect to other
members of the health care team.
6. AHCs are at a crossroads that demand an integrated and collaborative vision to improve interdisciplinary collaboration and professionalism
in a patient-centered integrated-care environment. What will not change
over time is a commitment to patients’ welfare, the duty to uphold scientific standards, and the importance of respectful engagement by all
disciplines.
UTMB has developed a systems approach to address and sustain its
commitment to professionalism and interprofessionalism. This strategy
elevates the primacy of professional and ethical behavior and demands it
as a core competency critical to the organization’s mission.
Professionalism is the standard of conduct for everyone at UTMB with
a clear recognition that everyone at UTMB is a member of a community
of professionals and it takes everyone to advance the university’s mission,
vision, and values.
References
1. Smith KL, Saavedra R, Raeke J, O’Donell AA. The journey to creating a
campus-wide culture of professionalism. Acad Med 2007; 82: 1015–21.
2. American Board of Internal Medicine. Project Professionalism.
Philadelphia (PA): American Board of Internal Medicine. Available at http://www.
abimfoundation.org/Resource-Center/Bibliography/~/media/Files/Resource20
Center/Project20professionalism.ashx.
3. University of Texas Medical Branch. UTMB Professionalism Charter.
Available at http://www.utmb.edu/professionalism/about-us/professionalismcharter.aspx.
4. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM
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6. Enhancing Interprofessional Profesionalism: A Systems Approach
Foundation, American College of Physicians-American Society of Internal
Medicine; European Federation of Internal Medicine. Medical professionalism
in the new millennium: A physician charter. Ann Intern Med 2002; 136: 243–46.
5. Medical Professionalism Project. Medical professionalism in the new
millennium: A physician’s charter. Lancet 2002; 359: 520–22.
6. University of Texas Medical Branch School of Medicine. Course
Information: Year 2 Practice of Medicine. http://www.utmb.edu/imo/courses/
year2/pom2.asp.
7. Muller D, Meah Y, Griffith J, et al. The role of social and community
service in medical education: The next 100 years. Acad Med 2010; 85: 302–09.
8. Cohen J. Our compact with tomorrow’s doctors. Acad Med 2002; 77:
475–80.
9. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the
structure of medical education. Acad Med 1994; 69: 861–71.
10. The Joint Commission. Sentinel Event Alert. Issue 40, July 9, 2008
Available at: http://www.jointcommission.org/assets/1/18/SEA_40.pdf.
11. Ainsworth MA, Szauter KM. Medical student professionalism: Are we
measuring the right behaviors? A comparison of professional lapses by students
and physicians. Acad Med 2o06; 81 (10 Suppl.): S83–86.
12. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional
behavior in medical school is associated with subsequent disciplinary action by a
state medical board. Acad Med 2004; 79: 244–49.
13. Hickson GB, Pichert, JW, Web LE, Gabbe SG. A complementary
approach to promoting professionalism: Identifying, measuring, and addressing
unprofessional behaviors. Acad Med 2007; 82: 1040–48.
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Chapter 7
Pursuing Professionalism
(But not without an infrastructure)
Gerald B. Hickson, MD, and William O. Cooper, MD, MPH
Y
ou are a senior leader in an academic medical center. A junior surgical resident you have worked with has scheduled time to discuss
some concerns:
Dr. Resident states: “I feel miserable and guilty about my failure.” Dr. Resident was
asked to insert a central line on a patient. “We were a little slow getting everything
assembled when Dr. Attending rushed in and asked, ‘You’re not finished yet? Which
part of my instructions did you not understand?’ I tried to explain. . . . Dr. Attending
just proceeded to take over and insert the line. The problem is his prep was quick
and he did not fully drape the patient. I just stood there. Now the patient is on
pressors in the ICU and her blood culture is growing staph. I feel responsible. I just
stood there. . . .”
As a medical leader within the health system, and as an individual with
responsibilities for mentoring students and residents, how might you
respond?
• Attempt to reassure Dr. Resident that a certain proportion of patients
get central line associated bloodstream infections and that the failure to
carefully prep is probably unrelated.
• Remind the resident of your physician wellness program, noting
that all professionals have patients with bad outcomes. Suggest that it is
important to understand these personal challenges early in a career and
learn how to cope.
• Explain to the resident that sometimes when professionals are busy
and stressed they can behave as described but that, “I know Dr. Attending
and he is a really committed clinician. He was probably just having one of
those days.”
• Encourage the resident to share the concern with risk management
and/or quality. “We have an event reporting system and you can always
report and even do so anonymously.”
• Contact Dr. Attending directly and share your concern about his
unprofessional behavior.
These options represent just a few of many available. The decision
about which action(s) to take in responding is complex and potentially
influenced by the answers to several questions. Is the story true? Should
you investigate to see if others observed the same event? But if the event is
true as presented and you talk to Dr. Attending, how will he respond? He
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Medical Professionalism: Best Practices
might thank you (but you doubt that will happen); he might even ask you
who reported him and then seek to retaliate (i.e., verbally challenging Dr.
Resident or negatively evaluating Dr. Resident’s performance). Who else
beyond Dr. Resident was impacted? What other health care professionals
observed Dr. Attending’s behavior? If leaders do not respond to verbal
assaults or failures to follow evidence-based practices, how will it affect
your culture of safety? Furthermore, isn’t it the duty of every professional
to do whatever is possible to prevent harm? On the other hand, if leaders
spend all of their time policing individuals who on occasion fail to wash
their hands or follow best practices in central line insertion, will there be
enough time in the day to accomplish other important activities? Who
wants to be a behavior monitor anyway?
How often do members of medical teams observe slips and lapses in
professional performance and conduct? How do we help leaders understand how best to weigh the pros and cons of acting when they either
observe or become aware of an event that seems inconsistent with the
highest standards of the profession?
We assert that whereas much is written about professionalism and its
noble tenets, far too little attention has been focused on understanding
a critical component of professionalism—the commitment to group and
self-regulation. We further assert that while it requires courage to examine
one’s own performance, it requires even more courage to assess and intervene on the behavior and/or performance of others. Furthermore, courage
by itself is not sufficient, and leaders will fail to achieve the success they
intend unless they are supported by the people, processes, and technology
that provide an infrastructure designed to address single lapses in professionalism and facilitate early identification and intervention for those who
appear to be associated with patterns of unprofessional behavior and/or
performance.
What is professionalism and professional self-regulation?
As you reflect on how to respond to Dr. Resident, you pause and reflect
on your personal goals for the practice of medicine and your view of what
it means to be a professional, as well as your group’s mission and goals for
care delivery. Specifically, how does being a professional inform or influence your decisions and interactions with patients, families, learners, and
colleagues?
Professionalism represents a commitment to cognitive and technical
competence and to certain behavioral attributes that promote optimal
team performance.1 These behavioral attributes include a commitment to
clear and effective communication, being available, modeling respect for
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others, and committing to reflect on how one’s own behavior impacts the
performance of others.
For example, professionals need to effectively communicate with peers
and other colleagues about plans, instructions, and expectations to promote best outcomes. Availability may take the form of physical presence
or response to communication, including answering pages for consults
from colleagues or from nurses who are concerned about a change in a
patient’s status. Failing to respond threatens team function and on occasion directly affects patient outcomes. How often do nursing professionals
hesitate to call and report a new finding because a clinician has a reputation for not responding or responding in a disrespectful way? We believe
that real professionals model respect for others and value the dignity of
all team members, including the patient and family. Finally, one of the
most important distinguishing requirements of a professional is the commitment to be reflective. When a professional experiences an unintended
outcome of care or is presented with a story or data suggesting his deviation from desired performance, he commits to reflect as appropriate and
adjust his behaviors and performance accordingly.
Professional accountability and reliability
As you review your conversation with Dr. Resident, you conclude that
public humiliation of a learner does not model respect and is not an effective means for communicating. That lapse should be addressed.
Failures to self- or group-regulate have a negative impact on all members of the health care team. Unprofessional behaviors, whether aggressive, passive-aggressive, or passive, threaten reliability and safety. Studies
of teams in business settings suggest that negative behaviors modeled by
one team member lead others to adopt negative mood and/or anger in
interactions with others.2,3 Unaddressed disruptive behaviors lessen trust
among team members and can contribute to worse task performance as
individuals are forced to monitor the disruptive professional’s behavior
and are not focused on their primary tasks. Distraction and lack of focus during medical practice contribute to slips and lapses.4,5 Finally, as
disruptive behaviors persist, team members may withdraw or leave the
organization entirely.6,7 Consider Dr. Attending’s behavior with the central
line insertion. Did his slip in professionalism “cause” the infection? It is
never really possible to know, but his performance had an impact on Dr.
Resident and perhaps on other team members in a variety of ways, including some team members who possibly may decide that it is acceptable to
deviate from evidence-based practice.
Over the past decade, medical educators have focused attention on
teaching many of the tenets of being professional.8–10 We assert however
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that the collective dialogue has failed to include sufficient attention to the
concept of self- and group-regulation and how to create effective plans
to address clinicians who model unprofessional performance. It may be
easier to sit in a lecture hall or classroom and discuss a vision of the noble
professional than to consider practical issues such as how to address Dr.
Attending’s behavior. A leader might think, “Besides, if we keep focusing on this ‘regulation’ stuff, I might actually have to go and talk to Dr.
Attending. He may not be so happy to hear from me, not refer patients to
me, seek to retaliate, or choose to leave.” Perhaps this is why professionals
often talk about each other, but not to each other.11
A second incident
You (Dr. Leader) decide to speak with Dr. Attending, but before you can
do so, a second event comes to your attention.
A nurse reported in your organization’s electronic event system: “Dr. Attending
was examining a patient with an abscess. When he entered the room he did not
foam in [wash his hands]. I offered a pair of gloves. He took the gloves from my
hand, smiled, and dropped them in the trash, and said, ‘No, thank you.’ He then
went back to examining the patient.”
Professionals need an infrastructure
Established policy in Dr. Leader’s hospital is for professionalism concerns to be entered into an electronic event reporting system. Such stories
are reviewed by authorized personnel from the Department of Quality
and Safety and then forwarded to a designated medical peer for face-toface delivery. Creating a process to accomplish reliable delivery promoting
accountability required years of work, dialogue, and consensus building.
The plan was developed with a set of core principles in mind, including
justice, data certainty, and a commitment to provide individual clinicians
the opportunity through feedback to develop personal insight.12 The
overarching goal was restoration, giving the clinician who has strayed an
opportunity to regain the honor of being a professional. Justice means
that all professionals are subject to the same rules with respect to performance, data sharing, and accountability. Justice requires that there are
no individuals with “special” value who for whatever reason are exempt
because they have unique clinical skills or generate high levels of clinical
revenue.12
Data certainty does not reflect the need for a p value <0.05, but refers
to the notion that in the context of the individual’s group or health system,
as reports begin to accumulate, sharing seems reasonable and is done in a
way that encourages personal insight.
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Insight includes “both intellectual and emotional awareness of the nature, origin, and mechanisms of one’s attitudes, feelings, and behavior,” 13
and is an essential prerequisite for individuals to take meaningful action
toward change with a goal for a restoration of professional behavior and
performance.
In reflecting about these guiding principles, we suggest that there are
eight elements of an infrastructure required to support professionals to
effectively and reliably handle the important challenge of self- and groupregulation.1,14 They include:
1. Leadership commitment
2. Vision, mission, core values, and supportive policies
3. Surveillance/measurement tools to capture observations/data
4. Process for reviewing observations/data
5. Model to guide graduated interventions
6. Multi-level professional/leader training about professionalism and
ways to equip clinicians to share data, promoting accountability
7. Resources to address the reasons that professionals fail to achieve
intended outcomes, including ineffective or failing systems and human
behavior
8. Resources to help other team members, patients, and families who
may have suffered psychological or physical harm related to the behavior
and performance of clinicians.
Of these eight elements, leadership commitment is key. By that we
mean the willingness to:1
• Hold all team members accountable for modeling right behaviors and
performance, whether related to washing hands, completing documentation, or treating other members of the medical team with respect.
• Enforce standards of practice and code of conduct consistently and
equitably among all regardless of seniority or “special” value to the organization. (Special value may be defined based on an individual’s unique skills
and ability, record in amassing a large number of research grants or clinical revenue, playing a critical role in a unique clinical service, or personal
or social relationships.) Real leaders will not “blink.”
• Honor and recognize professionalism in action. Positive reinforcement of clinicians who exceed expectations helps to publically demonstrate the organization’s commitment.
• Employ appropriate tools (i.e., reporting systems) designed to facilitate both early identification and reporting of slips and lapses in behavior
and performance, and to give feedback in ways designed to promote insight and self-regulation.
• Provide resources to build and maintain the infrastructure to support professional self-regulation efforts. Sustaining a reliable approach to
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professional regulation is not possible if it is supported only by individuals’
spare time.
Take a moment to reflect on the extent to which the system in which
you work models leadership commitment to address “early and often” the
behavior inconsistent with the concept of what it means to be a professional. In addition, think about your personal commitment to address
behavior and performance issues among your colleagues. If you happened
to walk into a unit and encountered Dr. Attending yelling at Dr. Resident,
would you be willing and able to act? Promoting professionalism requires
action.
Leaders also understand the need to create and disseminate vision
and mission statements with associated performance goals. Creating a
vision and mission is powerful. Consider the impact of the 100,000 Lives
Campaign, as professionals across the United States committed to implement six evidence-based interventions to improve patient safety. It has
been estimated that over 122,000 lives were saved as a result.15 A medical
group should also document its credo, a set of core values that define who
its members are. For example, the Vanderbilt University Medical Center
credo states: “I make those I serve my highest priority. I respect privacy
and confidentiality. I communicate effectively. I conduct myself professionally. I have a sense of ownership. I am committed to my colleagues.” 16
The elements of the credo are used to support performance evaluation,
reinforcing a commitment to principles of professionalism. They also may
be used to support dialogue between professional peers when an event occurs that appears to be inconsistent with the group’s core values. Finally,
new team members should be introduced to the group’s vision, mission,
goals, credo, and policies as a part of their onboarding. Such an approach
facilitates early communication in those uncommon but unfortunately
not rare circumstances when a new clinical colleague behaves in a way
inconsistent with her letters of recommendation.
Group, health system, or hospital policies governing professional behavior and performance should be written in a way that align them with
the credo and with a clearly articulated focus on safety. Medical groups
should delineate codes of conduct that include definitions of acceptable
and inappropriate behaviors. Policies should be developed that address a
lack of tolerance for egregious behaviors or certain behaviors for which
the law mandates a formal process for review,17 including alleged violations of sexual boundaries, inappropriate physical touching, assertions of
discrimination, or abuse. Finally, policies must outline clear protection
for those who report “events,” as the real or perceived threat of retaliation
represents formidable barriers to safe reporting. Leaders of health care
organizations must constantly be on guard for evidence of subtle and not
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7. Pursuing Professionalism (But not without an infrastructure)
so subtle ways that individuals seek to take retribution. Any confirmed
“assault,” verbal or otherwise, on a safety event reporter mandates an escalated response, including possible disciplinary actions.1
Necessary policies are effectively nullified when behaviors and performance inconsistent with the tenets of the profession and that undermine
a culture of safety go unreported and unaddressed. Therefore an effective infrastructure includes surveillance and measurement tools with
defined processes for data review and a tiered model for feedback and
accountability. The development of surveillance and measurement tools
and approaches for the review and sharing of data should include review
by a broad range of professional leaders who must explicitly declare
their support before specific individuals (i.e., performance outliers) are
identified. Too often, new initiatives are launched and professionals with
opportunities for performance improvement are identified, but leaders
“blink” by publicly challenging the metrics after they are established or by
rationalizing how in “this case” there exist special circumstances justifying the apparent poor performance. All of us are sometimes tempted to
rationalize, but professional leaders establish and pursue the established
plan regardless of who is identified—as long as the goal of the process is
to bring insight and restoration. It is imperative that leadership become
engaged early in the process and endorse each step of the data collection,
assessment, delivery, and potential consequences for failure to respond.
All members of the team need to understand the critical aspects of a
safety culture and accountability. Leaders should receive additional training on appropriate use of data and surveillance tools and how to promote
accountability. For example, it is useful for a leader to develop skills in
sharing observations of behavior that appear to undermine a culture of
safety, both for individual reports and when there appears to be a pattern.
Leaders should also be trained to identify various types of pushback and
how to appropriately respond.
In addition, resources for individuals who fail to respond to interventions might include physical and/or mental health evaluations and help in
addressing needs that might be identified. Resources for staff who may
be impacted by negative behaviors should be made available, including
critical incident debriefing or other resources through an employee assistance program.
Two important sources of data about professional performance deserve
detailed description—the reported direct observations of patients and of
medical team members, including other physicians, nurses, and allied
health personnel. Patients routinely observe the behaviors and performance of health care team members; they and their families may experience such things as:
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• Rude, disrespectful behavior—a patient who reported her physician
said, “You don’t need to ask questions. Just lay down here.”
• Failure to communicate clearly—“Dr. X ended the visit abruptly and
I had no idea what was supposed to happen next.”
• Lack of access—“We had the test over a month ago and no one called
us. Now we are told that there is a problem with the biopsy.”
If organizations are committed, they convey to patients that their observations are valued and that the organization “wants to hear from them.”
Such an approach facilitates service recovery, the effort to systematically
respond to any patient or family to address what they perceive is wrong.18
Even though most individuals who observe unprofessional behavior will
not speak up (perhaps only one out of forty to seventy dissatisfied patients),19 a subset will, and analysis of their stories provides important data
to support identification of professionals who model patterns of unprofessional conduct.19–23
Similarly, staff, including nurses, fellow physicians, and learners, observe their colleagues, and a subset will share their stories if they feel safe
and trust the medical group to use their observations for improvement.24
A nurse who reports through an event reporting system that a physician
failed to respond to several pages and then suggested that the issue “was
not her problem—call the cardiologist,” seems to be identifying a problem
with availability or taking responsibility. Another nurse who reports that a
physician interrupted her phone call describing a change in patient status,
asking her, “Are you stupid or are you illiterate? I wrote an order on this
patient forty-five minutes ago,” may be identifying an individual who has
a problem with respect for others.
A graded response to stories, reports, and data
To support the pursuit of professional regulation, Dr. Leader’s system
adopted a professional accountability pyramid to direct the process and
method of sharing.1 The pyramid is built on the fact that the vast majority of professionals are seldom involved in any questions of behavior or
performance. On the other hand, single events occasionally occur, like
the resident’s report about Dr. Attending’s failure to follow best practices
in line insertion. Staff observations are reviewed shortly after receipt by a
member of the safety team. The purpose of the initial review is to identify
any evidence of an event that requires a mandated evaluation (the black
triangle in the lower right of the pyramid), including assertions of sexual
boundary violations, physical assault, or assertions of discrimination or
abuse.1 Dr. Leader’s system also has embraced mandated reviews with
appropriate escalation and consequences for “egregious events” (the gray
triangle in the lower right of the pyramid), such as seeking to retaliate
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7. Pursuing Professionalism (But not without an infrastructure)
against someone who in good faith reports a safety concern. However,
most reports (by patients or staff ) do not call for mandated evaluation
and should be shared with the named professional in an informal, nonjudgmental, and respectful fashion (i.e., over a cup of coffee). For this
reason, Dr. Leader’s group has designated physician peer messengers by
department, who are trained to deliver the individual reports.
When Dr. Attending and the “gloves in the trash” incident was reported, it was
shared with the peer messenger. Dr. Peer called Dr. Attending and asked if they
could get together briefly in Dr. Attending’s office that day or the next. Once greetings concluded, Dr. Peer reminded Dr. Attending that staff members are encouraged to submit concerns about observed behaviors and performance that appear
inconsistent with the group’s credo. All such reports are reviewed and distributed
for delivery. The process was established to support a culture of safety and it is
assumed by the group that professionals want to know. At that point the essence
of the story was shared and Dr. Peer respectfully paused, offering Dr. Attending an
opportunity to respond. Dr. Attending paused briefly and then asserted, “I washed
my hands before I entered the room. I always foam in and I don’t know anything
about throwing any gloves into a trash can.” Dr. Peer responded, “I know you are
committed to our focus on hand hygiene. As far as the part about gloves, it just
didn’t seem like you [no point in disputing], but I have to wonder about the details
of the report. I just ask you to reflect back on the visit in question and I trust you
to do whatever you think is right [no mandated policy or required action]. Dr.
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Attending, you are a valued member of the team and that is why I am here to share
with you and others whenever such reports are received.”
The goal of a cup of coffee is to deliver a message about a single event
and provide an opportunity for individual self-regulation and personal insight. Peer messengers are taught that cup of coffee conversations are not
control contests or a chance to “fix” their colleagues. Such conversations
are short (three to five minutes) and generally not documented, though
the event precipitating the need for the conversation remains within the
surveillance system for future reference as needed.
Of note, Dr. Leader’s organization supports the timely delivery of professionalism reports without investigation if they do not represent egregious or mandated reporting events. Many if not most organizations and
medical groups encourage the investigation of stories. In our view, this
represents a process that increases conflict, seldom reveals the “truth,”
delays feedback, and is subject to the judgment of a few leaders who may
either choose to the “look the other way” or in rare instances use the
events to embarrass or humiliate. Because Dr. Leader’s group has an effective surveillance system, he or she can afford to be patient. If the event
is indeed isolated, there will not be additional reports entered into the
surveillance system. However, if the event reflects just one occurrence of
a pattern, there will most certainly be additional reports and opportunities
for feedback to the named clinician.
The pyramid is constructed anticipating that some professionals will
not respond to the cup of coffee, and those individuals will continue to
accumulate complaints. Linking the pyramid to longitudinal data collection for both patient and staff complaints allows the group or system to
establish thresholds to direct escalation as needed.1
Addressing potential patterns
It turns out that Dr. Attending has been mentioned in three previous
staff reports. The dropped gloves incident is a fourth report. What does
it mean to have three, four, or five reports in any defined time frame? A
leader will not know without a surveillance system, data review, and an
associated process to promote professional accountability.
Whenever clinicians are associated with a greater number of complaints than a threshold determined by the organization’s leadership, the
Chief Safety Officer prepares materials for review by the appropriate authority figure or authorized committee. Dr. Chair knows that eighty-five
percent of group members have no complaints, ten percent have only
one occasional complaint, and three percent (including Dr. Attending)
have four or more complaints during a three-year audit period. In fact,
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7. Pursuing Professionalism (But not without an infrastructure)
Dr. Attending is in the small group that accounts for over forty percent of
all documented professionalism concern reports. As the leader, Dr. Chair
decides to proceed with the awareness intervention as directed by the
professionalism pyramid.
The goal of an awareness intervention, whether delivered by an authority figure or peer as a member of a professionalism committee, is to
share with Dr. Attending that there appears to be a pattern of behavior
or performance inconsistent with the organization’s safety culture and to
encourage self-reflection. The visit also provides notice that if the unprofessional behavior continues, the leader may have to escalate the intervention and become directive. The visit is preceded with a letter stamped
confidential from Dr. Chair directed to Dr. Attending. The letter affirms
the importance that the medical group places on professionalism and
achieving the highest levels of patient safety and satisfaction. It reminds
Dr. Attending of the system-wide agreement to share staff reports and
reminds Dr. Attending that he has received several individual reports over
the past several months, as well as the fact that complaints have continued
to accumulate. He is reminded that the purpose of sharing is not to debate
the merits of any specific report, but to encourage Dr. Attending to consider why in the aggregate his practice seems to be associated with more
complaints than others. The letter serves as a request by Dr. Chair to set
up a visit in Dr. Attending’s office where the stories will be shared, as well
as other data to encourage reflection.
At the time of the visit, Dr. Chair thanks Dr. Attending for making time
and then proceeds to share the data suggesting that for some reason Dr.
Attending’s practice is associated with more staff complaints than others.
To support the assertion, Dr. Attending is provided the individual complaint narratives, a table illustrating complaint type themes (e.g., communication, medical care, responsibility, professional integrity), a figure
illustrating the distribution of all complaints about the physicians in the
system with Dr. Attending labeled, and a copy of the group’s professionalism policy. Dr. Chair provides several opportunities for Dr. Attending
to respond and ask questions. As the visit concludes, Dr. Chair affirms
that Dr. Attending is an important member of the team, but reminds Dr.
Attending that the accumulation of staff reports does not seem consistent
with the group’s collective commitment to professionalism. He is asked
to reflect on why it might be that his practice is associated with so many
complaints. Dr. Attending is reminded that he will continue to receive
follow-up about his complaint status on a regular basis and that most professionals who receive such peer-based feedback respond.1,19 The leader
is hopeful that Dr. Attending will respond as well. However “if complaints
continue there may have to be an escalation in the level of intervention.”
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Medical Professionalism: Best Practices
Training to conduct “awareness” interventions is case-based and
leaders/peer messengers are taught how to address common pushbacks.
In addition, training is designed to help leaders/peer messengers recognize and understand boundaries—awareness visits are not designed to be
directive, to make a diagnosis, or suggest a treatment plan. A challenge
faced by many leaders/messengers arises from a natural inclination to
coach. Whereas most leaders are likely to be correct in their recommendations, providing direction at this point is not respectful and does
not promote self-reflection and the self-regulation required in a safety
culture. Offering advice also sets the leader/messenger up for an all-toopredictable pushback. Whenever a leader/messenger offers a suggestion
and there is no subsequent evidence of performance improvement, when
follow-up occurs, the recipient very often responds, “I did everything you
suggested. This is all about your bad advice and one more example of your
poor leadership.”
Unfortunately, over the next few weeks Dr. Attending is named in two
additional professionalism concerns.
“I was shocked that Dr. Attending took a personal cell phone call right in the
middle of the procedure. . . . It was scary and upsetting.”
The next week a scrub nurse reported that during a stressful point in a surgical
procedure, Dr. Attending “grabbed the instrument out of my hand and told me to
get the hell out of his operating room.”
The group’s professionalism policy directs that Dr. Chair and Dr. Leader
are notified of the new reports and the need to consider a more directive
intervention. In a guided intervention, leaders review the data and develop a plan designed to address whatever they think may be contributing
to the problem, whether from a poorly functioning practice or system to
physical or mental health challenges that may be affecting Dr. Attending’s
performance.12 This level of professional help is possible only if collective
leadership ensures adequate resources are available for evaluation and
treatment. In our experience most individuals who reach the guided intervention level need to be directed for a mental and physical health screening evaluation. Prior to meeting with Dr. Attending, Dr. Chair develops a
written plan that is reviewed and approved by an appropriate leader (dean,
chief medical officer, or chief of staff ), outlining the group’s expectations,
Dr. Attending’s deficiencies (i.e., continued complaint generation), the
mandated intervention (i.e., referral for a screening health evaluation), the
potential consequence for failing to comply, the timeline for completion
of the evaluation, and ongoing monitoring of performance. The guided
intervention visit occurs in Dr. Chair’s office.
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7. Pursuing Professionalism (But not without an infrastructure)
While many individuals are able to, with appropriate assistance, address their unprofessional behaviors and reenter practice, a few will not.
At this point, institutional commitment supported by unified leadership
is critical, including policies that define unprofessional behavior, surveillance systems to permit reliable assessment and tracking of performance
over time, a process and method for promoting accountability, and resources to provide colleagues an opportunity to improve. We assert such
a process with predictable responses is fair, provides reasonable certainty
that a peer needs assistance, provides an opportunity for individuals to
develop personal insight, and allows change and restoration to the full
honor of the profession. If individuals fail to respond, it is not fair to other
members of the medical team that they continue to work, putting fellow
professionals and patients at psychological or physical risk.14,25-27
Does any of this work?
Does any of this work? Is there really any hope of restoring Dr.
Attending to the honor of the profession?
Support for a tiered approach to promote professional accountability is
provided by a series of studies examining ways to change physician practice performance. Ray et al. demonstrated the effectiveness of academic
detailing to improve physician prescribing practices, which resulted in
sustained reductions in the contraindicated practice of prescribing chloramphenicol and tetracycline to young children.28–30 An element of this
program’s success was data delivery by a professional peer and explanations that the colleague appeared to stand out from others. Building off
the success of Ray and others, our research team considered whether the
same methods (i.e., peer delivery of comparative data, delineation of expected professional norms supporting group accountability) would help
to reduce malpractice risk for the small subset of physicians by discipline
(two to eight percent) who are associated with a disproportionate share
of malpractice claims and payments.31,32 A series of studies showed that
high claims experience physicians stand out because they consistently
model behaviors described by their patients as unprofessional (e.g., being
rude, failing to respond to questions, and communicating poorly).21,22,31,33
High-risk physicians can be identified by coding and aggregating unsolicited patient complaint reports (a critical component of a professional
surveillance system), yielding an index that is strongly associated with
malpractice claims risk.31 In a study in a large academic medical center,
physicians at high risk (eight percent) were associated with more than
forty percent of all group claims and greater than fifty percent of all dollars paid for defense, awards, and settlement costs.31
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Medical Professionalism: Best Practices
In considering the best approach to promote personal insight and
practice change, we borrowed from the Ray model,30 and created the
Promoting Professionalism pyramid. Using an academic detailing model,
unsolicited complaint reports were shared in person by trained peer messengers with clinicians identified as being at high risk. High-risk professionals were asked to reflect on why their practice was associated with so
much dissatisfaction (compared with their peers) and therefore malpractice risk. Peer messengers encouraged professionals to consider changes
in their practices that might reduce their risk, but were specifically trained
not to coach the professionals. Since the first interventions, approximately
1,000 high-claims-risk physicians have been made aware that they appear
to stand out. The vast majority of those who receive interventions respond
with an eighty percent reduction in complaint risk score; a small number
require the more directed or guided interventions.34
The same process and method for sharing data was successfully used
in a health system-wide effort to improve hand hygiene rates.35 Failure
to follow hand hygiene best practice threatens safety and should be addressed in a fair and measured way. The infection prevention team created an aspirational goal, obtained leader and team member support,
developed and implemented a surveillance tool, and used the process and
model defined by the professional pyramid to promote accountability.
Data and performance expectations were shared with individuals and unit
leadership where improvement opportunities were identified. The coordinated effort resulted in improvements of hand hygiene from about sixty
percent to greater than ninety percent throughout the health system, and
an observed reduction in device-associated hospital-acquired infections.35
Improving care requires a level of commitment to the principle of professional self-regulation supported by a robust infrastructure, which aligns
with both the highest aspiration of the professional and society’s goals for
health care delivery.
What are the critical elements for success?
Creating an infrastructure as outlined in the following table is a requirement for any size clinical group interested in promoting professionalism and pursuing a safety culture. For Dr. Leader, the institution
had clearly stated values and a fair, equitable, and balanced process for
delivering interventions to Dr. Attending.
Such a system is built on trust. Individuals who report concerns either
as patients or colleagues must trust that the institution is committed to
reviewing and acting on information that suggests a “disturbance.” They
must also trust that if they speak up, even if they are mistaken in their
observations, they will be safe from retribution. Efforts to retaliate against
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7. Pursuing Professionalism (But not without an infrastructure)
reporters must be dealt with swiftly, even if only suspected. Colleagues
who appear to be accumulating too many stories must trust that data
will be shared in a non-judgmental way, giving them an opportunity to
respond. Leaders must trust that other leaders in the organization will not
“blink” under any circumstances, when, for example, an individual who
has received any level of intervention attempts to circumvent the chain
of command and appeal to a more senior leader. Leaders must fairly and
consistently hold all accountable. No one can have “special” status.
Infrastructure Elements for Promoting Process Reliability
and Professional Accountability
1. Leadership commitment
5. Model to guide graduated interventions
2. Mission, goals, core values,
and supportive policies
6. Multi-level professional/leader training (on
infrastructure and communication skills)
3. Surveillance tools to
capture observations and
reports
7. Resources to help address the causes of
unnecessary variation in performance (both system and individual)
4. Processes for reviewing
observations and reports
8. Resources to help those affected (psychological
or physical harm)
Professional to professional
During the guided intervention, Dr. Attending was presented with a letter directing him to report for a screening evaluation through the institution’s professional wellness program. The evaluation identified a number
of stressors in Dr. Attending’s life that he acknowledged were having an
impact on his practice. Review of the surveillance data confirmed that
the timing of Dr. Attending’s complaints appeared to correspond with his
life stressors. Supported by these observations, Dr. Attending’s personal
insight, the availability of professional mental health services, and a surveillance system to monitor Dr. Attending’s ongoing performance, Dr.
Chair decides that there is reason for optimism. If complaints continue
to accumulate, however, Dr. Attending will face disciplinary action as directed in the medical group’s bylaws. The hope is that a professional will
respond and again become a role model.
Conclusion
Training in what it means to be a professional is a fundamental part of
medical education for learners at all levels. The effectiveness of professionalism training is enhanced when conducted in a culture filled with
positive role models. Such a culture is not possible without personal
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Medical Professionalism: Best Practices
courage by leaders and professionals who understand the importance
of self- and group-regulation. Efforts at self- and group-regulation can
only be sustained if there is an established infrastructure to support
identification and intervention when individuals fail to live up to the
expected norms of the profession, including modeling respect for others
and a commitment to follow evidence-based practices. Training in what
it means to be professional must focus not solely on the noble tenets of
professionalism, but also on how to build, utilize, and sustain a supporting
infrastructure. In our opinion, to teach about the former in the absence of
teaching about the latter is unprofessional.
References
1. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary
approach to promoting professionalism: Identifying, measuring, and addressing
unprofessional behaviors. Acad Med 2007; 82: 1040–48.
2. Felps WM, Mitchell TR, Byington E. How, when, and why bad apples
spoil the barrel: Negative group members and dysfunctional groups. Research
in Organizational Behavior—An Annual Series of Analytical Essays and Critical
Reviews 2006; 27: 175–222.
3. Dimberg U, Öhman A. Behold the wrath: Psychophysiological responses
to facial stimuli. Motiv Emotion 1996; 20: 149–82.
4. Lewicki RJ, Bunker, BB. Trust in Relationships: A Model of Trust
and Development and Decline. In: Bunker BB, Rubin, JZ, editors. Conflict,
Cooperation, and Justice: Essays Inspired by the Work of Morton Deutsch. San
Francisco: Jossey-Bass; 1995: XX-XX.
5. Wageman R. The meaning of interdependence. In: Turner ME, editor.
Groups at Work: Theory and Research. Hillsdale (NJ): Lawrence Erlbaum
Associates; 2000: 197–218.
6. Schroeder DA, Steel JE, Woodell AJ, Bembenek AF. Justice within social
dilemmas. Pers Soc Psychol Rev 2003; 7: 375–87.
7. Pearson CM, Porath, CL. On the nature, consequences and remedies of
workplace incivility: No time for “nice”? Think again. Acad Management Exec
2005; 19: 7–18.
8. Mitchell P, Wynia M, Golden R, et al. Core Principles & Values of Effective
Team-Based Health Care. Washington (DC): Institute of Medicine of the National
Academies; 2012. https://www.nationalahec.org/pdfs/VSRT-Team-Based-CarePrinciples-values.pdf.
9. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team
behavior, and leadership engagement: The tools to achieve high reliability. Health
Serv Res 2006; 41 (4 Pt 2): 1690–1709.
10. Dupree E, Anderson R, McEvoy MD, Brodman M. Professionalism: A
necessary ingredient in a culture of safety. Jt Comm J Qual Patient Saf 2011; 37:
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447–55.
11. Moran SK, Sicher CM. Interprofessional jousting and medical tragedies:
Strategies for enhancing professional relations. AANA J 1996; 64: 521–24.
12. Reiter CE III, Pichert JW, Hickson GB. Addressing behavior and
performance issues that threaten quality and patient safety: What your attorneys
want you to know. Prog Pediatr Cardiol 2012; 33: 37–45.
13. Mosby’s Dictionary of Medicine, Nursing, & Health Professions. Ninth
Edition. St. Louis (MO): Mosby; 2012.
14. Hickson GB, Moore IN, Pichert JW, Benegas M Jr. Balancing Systems and
Individual Accountability in a Safety Culture. In: Berman S, editor. From the Front
Office to the Front Line: Essential Issues for Health Care Leaders. Second Edition.
Oakbrook Terrace (IL): Joint Commission Resources; 2011: 1–36.
15. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives
campaign: Setting a goal and a deadline for improving health care quality. JAMA.
2006; 295: 324–27.
16. Vanderbilt University Medical Center Credo; 2012. http://www.
mc.vanderbilt.edu/root/vumc.php?site=Elevatesite&doc=19079.
17. Joint Commission on Accreditation of Health Care Organizations. Sentinel
Event Alert 40: Behaviors that Undermine a Culture of Safety. Oakbrook Terrace
(IL): Joint Commission on Accreditation of Health Care Organizations 2008 Jul
9; 40. http://www.jointcommission.org/assets/1/18/SEA_40.PDF.
18. Hayden AC, Pichert JW, Fawcett J, et al. Best practices for basic and
advanced skills in health care service recovery: A case study of a re-admitted
patient. Jt Comm J Qual Patient Saf 2010; 36: 310–18.
19. Pichert J, Hickson GB. Patients as Observers and Reporters in Support of
Safety. In: Barach PR, editor. Pediatric and Congenital Cardiac Disease: Outcomes
Analysis, Quality Improvement and Patient Safety. London: Springer-Verlag; in
press 2014.
20. Carroll KN, Cooper WO, Blackford JU, Hickson GB. Characteristics of
families that complain following pediatric emergency visits. Ambul Pediatr 2005;
5: 326–31.
21. Moore IN, Pichert JW, Hickson GB, et al. Rethinking peer review:
Detecting and addressing medical malpractice claims risk. Vanderbilt Law Rev
2006; 59: 1175–1206.
22. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient
satisfaction with complaints against physicians and malpractice lawsuits. Am J
Med 2005; 118: 1126–33.
23. Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of
moral distress: Development of a web-based survey. Acad Med 2010; 85: 111–17.
24. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes:
Perceptions of nurses and physicians. Am J Nurs 2005; 105: 54–64; quiz 64–65.
25. Catchpole K, Mishra A, Handa A, McCulloch P. Teamwork and error in
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the operating room: Analysis of skills and roles. Ann Surg 2008; 247: 699–706.
26. Mishra A, Catchpole K, Dale T, McCulloch P. The influence of nontechnical performance on technical outcome in laparoscopic cholecystectomy.
Surg Endosc 2008; 22: 68–73.
27. Shouhed D, Gewertz B, Wiegmann D, Catchpole K. Integrating human
factors research and surgery: A review. Arch Surg 2012; 147: 1141–46.
28. Ray WA, Federspiel CF, Schaffner W. Prescribing of chloramphenicol
in ambulatory practice. An epidemiologic study among Tennessee Medicaid
recipients. Ann Intern Med 1976; 84: 266–70.
29. Ray WA, Federspiel CF, Schaffner W. Prescribing of tetracycline to
children less than 8 years old. A two-year epidemiologic study among ambulatory
Tennessee medicaid recipients. JAMA 1977; 237: 2069–74.
30. Schaffner W, Ray WA, Federspiel CF, Miller WO. Improving antibiotic
prescribing in office practice. A controlled trial of three educational methods.
JAMA 1983; 250: 1728–32.
31. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and
malpractice risk. JAMA 2002; 287: 2951–57.
32. Hyman DA, Sage WM. Medical malpractice in the outpatient setting:
Through a glass, darkly. JAMA Intern Med 2013; 173: 2069–70.
33. Mukherjee K, Pichert JW, Cornett MB, et al. All trauma surgeons are not
created equal: Asymmetric distribution of malpractice claims risk. J Trauma 2010;
69: 549–54.
34. Pichert JW, Moore IN, Karrass J, et al. An intervention model that
promotes accountability: Peer messengers and patient/family complaints. Jt
Comm J Qual Patient Saf 2013; 39: 435–46.
35. Talbot TR, Johnson JG, Fergus C, et al. Sustained improvement in hand
hygiene adherence: Utilizing shared accountability and financial incentives. Infect
Control Hosp Epidemiol 2013; 34: 1129–36.
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Remediation
99
Chapter 8
Clinical Skills Remediation: Strategy for
Intervention of Professionalism Lapses
Anna Chang, MD
T
his chapter brings the literature and practice of clinical skills guidance and remediation in medical education to the discussion of
best practices in medical professionalism. First, it describes differences, and then similarities, between the approaches to low performance
in clinical skills and professionalism. Next, it examines the applicability of
a five-step clinical skills remediation and guidance strategy to address professionalism lapses. Finally, it suggests individual and systems approaches
to the remediation of learners and colleagues who need guidance in medical professionalism.
Case example from clinical skills
Dear Student,
We regret to inform you that you have failed your clinical skills examination in
the areas of history-taking, physical examination, clinical reasoning, and patient
communication skills. Your performance is in the lowest 2 of the class and your
score does not meet the minimum threshold for passing. You are now required to
meet with the course director for remediation . . .
Letters like this notify some medical students each year of unexpected
failing performance on clinical skills examinations. At one medical school,
this notice at the end of a foundational clinical skills course informs a
handful of second-year students about performance that is below expected
competence on a multi-station standardized patient objective structured
clinical examination (OSCE) final examination. Since the 1990s, most U.S.
medical schools have required student participation in standardized patient clinical skills examinations, with a median annual cost of 50,000 per
examination in 2005.1 For most medical students, examinations like this
are among the first in a series of high-stakes clinical skills examinations
to ensure that they achieve minimum expected competence in the clinical
skills required to advance to medical school graduation, residency entry,
and board certification.1
Studies have reported strategies to guide the steps following a student’s
failure to progress to the next stage of training because of below-expected
competence performance compared with milestones in the competency
domain of patient care.2 In recent years, scholarship in this area has
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examined various aspects of guidance and remediation in medical education, from tools for early identification of struggling learners, to the effect
of performance data on learning goals, to systematic reviews of remediation processes among U.S. medical schools.3–6 Thus, the field of clinical
skills guidance and remediation is on the path of building an evidence base
of best practices to guide educators and institutions.
Clinical skills versus professionalism: Differences
Many educators would likely point out some important differences
between the approach to assessment and remediation of clinical skills and
the approach applied to lapses in medical professionalism.
First, structured checklists along with global rating scales are now
routinely used in assessment and standard-setting of formative and summative clinical skills examinations.1,7 Faculty members or standardized
patients complete checklists after simulated clinical encounters.7,8 Passing
performance can be determined by criterion-referenced or normative
standard setting methods.1,8 In other examinations, checklists of key
history or physical examination items are applied to the written postencounter clinical note to assess the learners’ clinical reasoning.8 These
real or standardized patient examinations with the use of checklists occur
multiple times throughout medical school, and students are no longer allowed to advance to licensure without demonstrating clinical skills competence.9 Similar assessment systems may be less consistently applied to
the competency domain of professionalism.
Second, identification and remediation of deficits in the technical aspects of clinical skills may be perceived as less emotional, and therefore
easier, for both faculty and learners than lapses in professionalism. Faculty
members find it challenging to fail learners.10 “Millennial generation”
learners thrive with positive feedback.11 One study shows that students
are more likely to give constructive feedback about technical deficits (e.g.,
physical examination technique) when randomly grouped with peers.12
Only after longitudinal peer cohorts have spent years together do students
begin to develop the trust and comfort that allows them to give constructive feedback about more personal and interpersonal learning needs (e.g.,
communication skills).12 Thus, it is possible that low performers in general
clinical skills may be identified with more ease than those who demonstrate professionalism lapses.
Third, most schools have additional guidance programs for clinical
skills deficits, as well as processes to measure improvement after remediation.2,6 Structured remediation programs for the more technical skills
of medicine, such as key history items or physical examination technique,
are common in medical schools today.2,6,13 On the other hand, similar
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8. Clinical Skills Remediation: Strategy for Intervention of Professionalism Lapses
pre-existing systems to support learners with professionalism lapses are
rarely reported in the literature, may not be as prevalent in practice, and
may develop on an ad hoc basis in response to individual issues.14 Faculty
members hesitate to point out learner performance deficits for multiple
reasons, particularly if they are uncertain about the availability of remediation options.10 The lack of remediation programs in professionalism may
affect the identification of those with professionalism lapses. Furthermore,
most medical schools repeat the clinical skills examination after remediation programs, and almost all schools report having a process to reassess
clinical skills competence.6 Thus, one approach to begin to close the gap
of differences is to develop similarly robust identification, remediation,
and reassessment processes for learners and colleagues in the domain of
medical professionalism.
Clinical skills and professionalism: Similarities
There are also notable similarities between the principles and steps in
working with those with additional learning needs in clinical skills and in
medical professionalism.
First, learners demonstrate their abilities in clinical skills or professionalism, as well as in other competency domains, in overlapping and
integrated ways while participating in many of the same activities in
the classroom environment and in the clinical setting.15 The movement
towards the use of entrustable professional activities as an educational assessment framework advocates for the unit of measurement of physician
skills to be an integrated activity, rather than deconstructed competencies.16 Viewed through this lens, skills in history taking, physical examination, communication, and professionalism are interrelated elements of a
single connected whole.
Second, the strategy for remediation in any competency domain begins with identification of those who are performing poorly compared
to performance standards using objective measurement tools.2 The low
performer then receives performance data and feedback, as well as guidance to develop effective learning plans that target the deficit.6 The plan
is put into action for a period of time, and the learner is then retested by
objective measures to determine the outcome of remediation.2 With these
steps, the approach to low-performing learners in both clinical skills and
professionalism can be remarkably similar.
Finally, competence in general clinical skills and competence in medical professionalism are intertwined and essential to the physician’s role
on the clinical team, and the physician’s duty to patients.17,18 For example,
communication skills as applied to gathering and sharing information are
among the most important clinical skills in the patient encounter, and are
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Medical Professionalism: Best Practices
simultaneously crucial for aspects of professionalism that involve interactions with the patient. As such, the outcomes of remediation for both have
meaning for individual patient care as well as health care systems. Thus,
the reasons for, and end result of, remediation for both general clinical
skills and medical professionalism have significant impact on outcomes
such as patient safety, patient satisfaction, and quality of care.
Why remediate?
But if I accept you as you are, I will make you worse; however if I treat you as
though you are what you are capable of becoming, I help you become that.
—Goethe
Despite individual and systems challenges inherent to each step of the
process—from identification of low performers, to accurately describing the deficit, to designing a remediation program, to measuring outcomes—there are important reasons to pursue this path for learners in
need. Medical educators hold a dual responsibility to their learners and to
their learners’ future patients. To fulfill the responsibility to their learners,
educators must begin with the belief that each person has the ability to
improve his or her performance and has the right to receive feedback and
guidance that contribute to continued development as a professional. To
fulfill the responsibility to their learners’ future patients, educators need
to assess learner performance with objectivity, apply skillful communication with courage to describe any deficits, and commit to participate in
remediation whenever appropriate.
The following section describes a step-wise strategy for remediation
drawn from lessons learned from clinical skills that can be adapted and
applied to work in medical professionalism.
A sample remediation strategy in five steps:
Closing the gap between performance and expectations
This five-step strategy, beginning with identification of the deficit
and ending with measurement of outcomes after remediation, can be
used to frame the approach to helping learners with lapses in medical
professionalism.
Step 1: Early Identification
The first step calls for early identification of learner deficits—a challenge for educators. As noted earlier, faculty can be reluctant to point
out trainee problems for a number of reasons, including lack of documentation, lack of knowledge of what to document, the anticipation of
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8. Clinical Skills Remediation: Strategy for Intervention of Professionalism Lapses
a negative experience with an appeals process, and lack of remediation
options.10 Furthermore, medical educators are invested in the success of
their learners, and cognitive psychologists have demonstrated that commitment to a process (e.g., teaching) can result in a higher likelihood of
believing in positive results (i.e., learner competence) even if evidence
exists to the contrary.19 This belief may tempt educators to search for, or
accept, situational reasons for poor performance from their learners. But
to consistently achieve optimal learner performance, it is important to
keenly differentiate between one-time contextual events and patterns of
repeated low performance that point to a need for additional guidance.
The importance of early identification is confirmed by studies demonstrating that performance deficits, if not identified and addressed,
tend to persist. Klamen et al. described a statistically robust correlation
between low performance in clinical skills examinations in year two and
in year four (OR 20, p=o).4 Chang et al. reported that communication
and professionalism deficits reported in core clerkship ratings (OR 1.79,
p=0.008) and student progress review meetings (OR 2.64, p=0.002) predict failure in year four clinical skills examinations.3 Studies show that
early identification allows learners who need additional guidance the time
and opportunity to develop and enact targeted learning plans to improve
performance.20
When confronted with data of low performance after high-stakes assessments in the later years of school, students often ask: “Why didn’t
you tell me this earlier?” Studies confirm that educators do have data to
identify learners with a pattern of professionalism lapses, and that sustained difficulties tend to track over time.3,21 While educators may wish to
believe that silence is kinder or allows learners more time to improve on
their own, this erroneous assumption can actually hurt both learners and
their future patients. Thus, early identification is an important first step.
Step 2: Objective data
This step identifies the gap by using objective measures or measurements to compare the learner’s performance with expected milestones.
For medical knowledge and clinical skills, a number of assessment tools
are routinely used, including written examinations, oral examinations,
simulated and real patient OSCEs, global ratings, direct observation,
portfolio, 360° evaluation, etc.22 Fifty-five tools were identified just for
direct observation of clinical skills with real patients.23 Approximately
eighty to ninety percent of U.S. medical schools conduct simulated clinical skills examinations in years two, three, or four.1 The majority (80)
use standardized patient checklists, and some (21) use faculty checklists
or global assessment scales to score clinical encounters.2 Most (60) use
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Medical Professionalism: Best Practices
normative grading strategies, with the rest using criterion-referenced
(21) or a combination (18).2
While there are flaws and challenges with any single assessment tool,
there are important reasons to apply a combination of assessment tools
to determine performance in every competency domain.22 First, multiple
groups of assessors (e.g., teachers, peers, standardized patients, real patients, clinical staff ) can identify in learners similar deficits using different assessment tools at different times.3 Second, even assessment tools
designed primarily for measuring performance in one domain (e.g., clinical reasoning in a clinical skills examination) can identify lapses in performance in other domains (e.g., fabrication of clinical findings pointing
to lapses in knowledge and professionalism).15,24 To move successfully to
the next step in this remediation strategy, it is important that the educator
and the learner use the same data to establish agreement about the gap
between performance and expectations.
Step 3: Shared understanding
After objective data establishes a gap between performance and expectations, the learner and the educator begin the process of building a
shared understanding. Educators begin with the knowledge that learners
need data and guidance—not just data alone—to identify their deficits
and learning plans.25 This guidance begins with a one-on-one meeting
between the student and the educator in which a conversation about
performance is built on a foundation of rapport, trust, and support.13
Important techniques include listening, summarizing, responding to emotions, expressing support, and redirecting towards the learning objective.
Some sample words to use include:
• “We are meeting today to discuss your performance in . . .”
• “What is your interpretation of . . .”
• “Here are some additional perspectives on . . .”
• “May we agree to work on improving . . .”
Some educators assume that learners will be able to correctly identify
their learning needs and develop corrective plans on their own if given numerical and narrative evidence of low performance and even comparative
cohort data. But in one study, only half of all students who failed a highstakes clinical skills examination in the area of communication skills were
able to develop learning goals in that area without faculty guidance, even
after receiving individual and comparative examination results indicating
failing performance, in both qualitative and quantitative formats.25 This
has potential implications for remediation in professionalism lapses. The
debate to reach agreement on a shared definition of low performance in
communication skills and professionalism skills can become mired in gray
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8. Clinical Skills Remediation: Strategy for Intervention of Professionalism Lapses
areas considered to be subjective, personal, emotional, and challenging.
With low performing learners, educators cannot simply deliver performance data and leave learners alone to determine accurate next steps for
improvement without guidance.26,27
Step 4: Learning plans
The strategy continues with a focus on two aspects of the learning plan:
writing effective learning plans, and putting them into action.
After the educator and the learner have established a shared understanding of the learning gap as well as explored the need to develop
targeted learning plans, the learner should be encouraged to initiate the
process of drafting learning plans.25 This step is important in reinforcing
learner ownership and commitment, as well as demonstrating to educators where learners are starting from in their understanding and synthesis
of the information thus far. One common acronym is SMART, indicating
that effective learning plans are specific, measurable, attainable, relevant,
and time-bound.28 A sample ineffective learning plan might be: “I will read
more” or “I will not be late.” More effective learning plans are specific (e.g.,
“I will practice X skill”), measurable (e.g., “with the next three patients to
achieve Y performance level”), and time-bound (e.g., “over the next two
weeks). One study demonstrated that ninety-six percent of fourth-year
students write specific learning goals with minimal written instructions.25
However, without guidance, learners may not choose to write learning
plans that address the most important areas of deficit, or may not know
how to develop an effective plan to address target deficits.25
Putting learning plans into action may include sequential or multipronged approaches of deliberate practice in different formats and settings. Strategies include meetings between the faculty and the learner for
role play and practice, additional or elective clinical experiences in environments that allow skills building, standardized patient cases in simulated clinical skills environments, peer learning, small groups observation
and feedback, and others.2,6,27,29–31
Many U.S. medical schools employ group learning activities for deliberate practice in the context of remediation.6 Peer learners, even those who
have additional learning needs themselves, are effective teachers and feel
safe in small group settings in the context of remediation.29 While educators’ confidence in their own ability to help learners remediate is generally
low and is lowest for professionalism (2.96 on a scale of 1 = strongly disagree to 5 = strongly agree), their confidence increases with group practice
options for learners.6 In other words, when faculty are able to access group
learning activities as a tool for remediation, they feel more confident
participating in remediation for learners with lapses in professionalism.
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Medical Professionalism: Best Practices
Learners also may perceive feedback from peers as being more authentic,
less threatening, and more understandable. Observation shows that learners have different strengths and weaknesses, and often complement each
other when learning in small groups. Perhaps simply sharing the task of
remediation in the form of group activities builds a learning community
and decreases the resistance and activation energy needed for identification and remediation.27
Step 5: Measuring outcomes
The final step of this strategy is the measurement of outcomes after remediation. This remains a challenging task in every competency domain.
The precise definition of developmentally appropriate performance goals,
assessment tools, and standard setting strategies can seem to be elusive
moving targets.
Approximately seventy-five percent of schools report retesting after
clinical skills remediation with the same or different standardized patient
examination cases.6 However, many repeat examinations are less complex or more targeted in an effort to assess for minimum competence.
The complexities of different standard-setting strategies likely also affect
individual outcomes. With normative standard setting, educators find it
challenging to choose the most appropriate cohort for comparison. Since
the examination itself is often different from the original, educators are
challenged with applying criterion-based scoring strategies to a retest
applicable to only a few learners because it can require an intensive time
investment from a group of experts to define appropriate cutoff scores.8
And finally, with different competency-based education frameworks,
educators debate the use of combinations of frameworks consisting of
developmentally progressive milestones, non-overlapping competencies,
or integrated entrustable professional activities, or others.32 Thus, while
somewhat cleaner measurement tools exist for clinical skills performance,
more science is needed in both clinical skills and professionalism in assessment of remediation outcomes.
Summary: The science, the art, and the unknown of
remediation
The science of remediation
The literature of remediation in medical education has been active
since 2000, yet the science is still young. In the area of clinical skills remediation, scholarship has included surveys of medical school remediation processes, systematic reviews of remediation programs, books with
expert recommendations, studies showing early identification predictors
of struggling learners, and limited outcomes of remediation. In terms of
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8. Clinical Skills Remediation: Strategy for Intervention of Professionalism Lapses
timeline, the domain of clinical skills may be somewhat ahead of that on
medical professionalism in building a robust body of work on assessment
tools and remediation strategies. However, the progress made in defining
medical professionalism lays the groundwork for next steps in practice
and research, which may include development and validation of assessment tools, studies of remediation strategies, and descriptions of learner
and systems outcomes.
The art of remediation
Success factors in the practice of remediation are rooted in the human
experience of learning and achievement. Early identification of struggling
learners is critical to allow for early intervention, which is often fruitful.
The educator and learner begin with a one-on-one meeting to establish
trust, safety, and shared goals. They then agree on performance data, performance expectations, and learning plans. One recommendation worth
considering is framing the process as guidance for continuous improvement of performance rather than as remediation for failing performance.
Educators could describe an invitation-only guidance program aimed at
increasing the learner’s future performance. This simple reframing can
help learners to begin with an open mind for learning rather than dwelling
on blame or shame. A second recommendation is to challenge the learner
to actively initiate and own the process of learning. One example is having
learners write and revise their own learning plans with faculty guidance
along the way. Sometimes educators can be so eager to teach that they
take over learner tasks in active learning. Expectations of active learning
prevent the occasional surprising discovery of how little might be retained
by the passive learner at the end of intense teaching.
The unknown of remediation: Shared challenges between remediation
of clinical skills and professionalism lapses
Finally, there are remarkable parallels between the domains of clinical skills and medical professionalism in what remains to be learned in
remediating learners or clinicians whose performance is below expected
competence. These questions remain:
• What is the deficit?
• Do we aim to change the learner’s attitude, or is changing behavior
sufficient?
• What are effective strategies to guide learning in remediation?
• How do educators reserve time for remediation in the core
curriculum?
• How do we systematically document performance after deliberate
practice?
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Medical Professionalism: Best Practices
• What data contribute to reassessment other than absence of negative reports?
• What if improvement is not consistent across settings or over time?
• What is the end point of remediation?
– For example, is it when the learner demonstrates adequate performance once, or more than once? In one context, or in more
than one?
– Is it when educators have built such a robust scaffold around
these learners to get them barely over the threshold of competence that it cannot be sustained in a busy health care system to
maintain adequate performance?
– Or is remediation over when we find out that the behavior cannot be changed?
The future of remediation in the field of medicine should include studies of effectiveness of remediation strategies, data on long-term learner
and patient outcomes after remediation, and the development of comprehensive systems approaches to professional development that cross silos
of competency domains or course structures. In addition, participating in
remediation may be an opportunity for learners to gain insight into generalizable ways to improve performance. Ultimately, effective learning programs initially developed for remediation could be expanded to improve
everyone’s performance with individual learning plans in all competency
domains, and not just those who have already demonstrated lapse or failure. In this way, remediation programs would become one part of a whole
system of competency-based learning and assessment in the continuum
of lifelong learning, from undergraduate medical education, to graduate
medical education, to clinical practice.
Conclusions
Effective practices of guidance and remediation for clinical skills and
medical professionalism are important to medical education and clinical medicine. Lessons learned and practical strategies from clinical skills
remediation can be adapted and applied to guidance of those with professionalism lapses. Systematic approaches to remediation in the domain of
medical professionalism would move the field forward in fulfilling our
duty to our colleagues and our patients.
Acknowledgments
Dr. Chang’s work on clinical skills remediation was supported by the University
of California San Francisco (UCSF) School of Medicine, the UCSF Haile T. Debas
Academy of Medical Educators Innovations Funding Program, and the UCSF
Medical Education Research Fellowship. Her work in clinical skills assessment is
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8. Clinical Skills Remediation: Strategy for Intervention of Professionalism Lapses
informed by participation as a member school faculty in the California Consortium
for the Assessment of Clinical Competence, and as faculty on the Test Materials
Development Committee for the National Board of Medical Examiner’s USMLE
Step 2 Clinical Skills Examinations.
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student clinical skills assessment. Acad Med 2005; 80 (10 Suppl): S25–29.
2. Hauer KE, Teherani A, Irby DM, et al. Approaches to medical student
remediation after a comprehensive clinical skills examination. Med Educ 2008;
42: 104–12.
3. Chang A, Boscardin C, Chou CL, et al. Predicting failing performance
on a standardized patient clinical performance examination: The importance of
communication and professionalism skills deficits. Acad Med 2009; 84 (10 Suppl):
S101–104
4. Klamen DL, Borgia PT. Can students’ scores on preclerkship clinical
performance examinations predict that they will fail a senior clinical performance
examination? Acad Med 2011; 86: 516–20.
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JAMA 2002; 287: 226–35.
8. Wass V, Van der Vleuten C, Shatzer J, Jones R. Assessment of clinical
competence. Lancet 2001; 357: 945–49.
9. Papadakis MA. The Step 2 clinical-skills examination. N Engl J Med 2004;
350: 1703–05.
10. Dudek NL, Marks MB, Regehr G. Failure to fail: The perspectives of
clinical supervisors. Acad Med 2005; 80 (10 Suppl): S84–87.
11. Bing-You RG, Trowbridge RL. Why medical educators may be failing at
feedback. JAMA 2009; 302: 1330–31.
12. Chou CL, Masters DE, Chang A, et al. Effects of longitudinal small-group
learning on delivery and receipt of communication skills feedback. Med Educ
2013; 47: 1073–79.
13. Chang A, Chou CL, Hauer KE. Clinical skills remedial training for medical
students. Med Educ 2008; 42: 1118–19.
14. Hauer KE, Ciccone A, Henzel TR, 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: 1822–32.
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15. Teherani A, O’Sullivan P, Lovett M, Hauer KE. Categorization of
unprofessional behaviours identified during administration of and remediation
after a comprehensive clinical performance examination using a validated
professionalism framework. Med Teach 2009; 31: 1007–12.
16. ten Cate O. Entrustability of professional activities and competency-based
training. Med Educ 2005; 39: 1176–77.
17. Irvine D. The performance of doctors. I: Professionalism and self regulation
in a changing world. BMJ 1997; 314: 1540–42.
18. Irvine D. The performance of doctors. II: Maintaining good practice,
protecting patients from poor performance. BMJ 1997; 314: 1613–15.
19. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and
Giroux; 201o.
20. Klamen DL, Williams RG. The efficacy of a targeted remediation process
for students who fail standardized patient examinations. Teach Learn Med 2011;
23: 3–11.
21. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by
medical boards and prior behavior in medical school. N Engl J Med 2005; 353:
2673–82.
22. Epstein RM. Assessment in Medical Education. N Engl J Med 2007; 356:
387–96.
23. Kogan, JR., Holmboe ES, Hauer KE. Tools for direct observation and
assessment of clinical skills of medical trainees: A systematic review. JAMA 2009;
302: 1316–26.
24. Friedman MH, Connell KJ, Olthoff AJ, et al. Medical student errors in
making a diagnosis. Acad Med 1998; 73 (10 Suupl): S19–21.
25. Chang A, Chou CL, Teherani A, Hauer KE. Clinical skills-related learning
goals of senior medical students after performance feedback. Med Educ 2011; 45:
878–85.
26. Durning SJ, Cleary TJ, Sandars J, et al. Perspective: Viewing “strugglers”
through a different lens: How a self-regulated learning perspective can help
medical educators with assessment and remediation. Acad Med 2011; 86: 488–95.
27. Steinert Y. The “problem” learner: Whose problem is it? AMEE Guide No.
76. Med Teach 2013; 35: e1035–45.
28. Hamilton M. Putting words in their mouths: The alignment of identities
with system goals through the use of Individual Learning Plans. Brit Educ Res J
2009; 35: 221–42.
29. Chou CL, Chang A, Hauer KE. Remediation workshop for medical
students in patient-doctor interaction skills. Med Educ 2008; 42: 537.
30. Cleland J, Leggett H, Sandars J, et al. The remediation challenge:
Theoretical and methodological insights from a systematic review. Med Educ
2013; 47: 242–51.
31. Kalet A, Chou CL. Remediation in Medical Education: A Mid-Course
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Correction. New York: Springer; 2013.
32. Pangaro L, ten Cate O. Frameworks for learner assessment in medicine:
AMEE Guide No. 78. Med Teach 2013; 35: e1197–210.
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Chapter 9
Remediating Professional Lapses of
Medical Students: Each School an Island?
Richard M. Frankel, PhD
Remediation: (Latin) Mederi = to heal + re = again.
Definition: to put right or reform1
I
recently attended the Association of American Medical Colleges
(AAMC) 2014 Midwest Regional Group on Educational Affairs
Meeting in Cleveland, Ohio, where my colleagues and I conducted a
workshop on remediating professionalism lapses among medical students.
At the beginning of my portion of the workshop, which was devoted to
describing the professionalism remediation program at Indiana University
School of Medicine, I asked the audience of sixty or so participants, ”How
many of you approach your remediation meetings with students with
optimism, energy, and enthusiasm?” Not a single hand was raised. I then
asked, ”How many of you have received any formal training in how to
conduct remediation meetings with students or are aware of any national
guidelines or best practices in this area?” Again, no hands were raised.
Finally, I asked, “How many of you have on your bucket list of things you
want to accomplish in your medical education careers remediating medical student professionalism lapses? Amidst smiles and laughter, no one
responded by raising a hand.
After having served as the professionalism competency director at a
large medical school for nine years, and as a medical educator with three
decades of experience, I was not surprised by these responses. In fact,
they confirmed or reconfirmed elements of my own experience, namely,
that remediation of professional lapses among medical students can be
challenging; that each faculty member responsible for professionalism
remediation works in isolation, and that there are few specific resources
available for how to effectively conduct remediation encounters with
students. The one area that felt at odds with my own experience was the
bucket list question. Although it was not on my list initially, I have found
my remediation encounters with students to be immensely rewarding and
meaningful.
My goals in this chapter are threefold: first, I describe the professionalism competency program at Indiana University School of Medicine and
the steps involved in the remediation process; next, I present three cases
to illustrate my approach to the remediation encounter and its similarities
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to interviewing difficult patients; finally, I offer analysis, commentary, and
suggestions for some steps that might be taken to stimulate national dialog
around remediation processes and outcomes.
In the beginning . . .
In October of 2004, I became the third professionalism Competency
Director (CD) at Indiana University School of Medicine, a position that
was created in 1999 when the school adopted what was then only the second comprehensive undergraduate medical school competency curriculum in the United States. The curriculum was adopted after seven years of
self-study and covered nine core competencies, including:
1. Effective communication
2. Basic clinical skills
3. Using science to guide diagnosis, management therapeutics, and
prevention
4. Life-long learning
5. Self-awareness, self-care, and personal growth
6. The social and community contexts of health care
7. Moral reasoning and ethical judgment
8. Problem solving
9. Professionalism and role recognition.
The overall competency curriculum has been fully implemented since
1999. Each competency has a statewide director, a portion of whose salary
is paid by the Dean’s Office.
Figure 1
Professionalism in a Box
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9. Remediating Professionalism Lapses: Each School an Island?
In my first week as CD, a box (see Figure 1) with articles, books, pamphlets, and videotapes was delivered to my office from the previous director, who had retired and moved to another state. The accompanying note
congratulated me, wished me well, and said that the box contained all the
material on professionalism that he had collected during his tenure. I was,
of course, happy to get the material and immediately began digging into
its contents. Many of the papers defining professionalism were familiar to
me from work and teaching I had already done in the area. So, too, were
the debates about whether professionalism consists of a set of timeless
precepts and values or whether it is more like a complex adaptive system,
a complex contextual cultural construct that changes as societal attitudes
and values change.2–7 As important and complex as this debate was, what
struck me as interesting, and somewhat concerning considering the fact
that I was going to have to do real-time remediation meetings with medical students, was the scarcity of material on how to actually conduct such
meetings. As I reviewed the published literature I became alarmed about
the paucity of research and outcome studies that have looked at best
practices for remediating clinical skills in general,8 and professionalism
lapses of undergraduate medical students, in particular.9,10 What there
was tended to be based on small samples from individual schools with
little practical guidance on what to look for, how to act, and how to assess success or failure of remediation efforts, especially given the gravity
of decisions being made about students’ career aspirations in medicine.
For example, Buchanan et al. suggest the following steps be taken in the
remediation encounter: (1) confirm the lapse, (2) understand the context,
(3) communicate and discuss in a mutually respectful manner, (4) encourage self-reflection, (5) agree on a plan for remediation, (6) document the
interventions, and (7) construct a plan for follow-up.11 While checklists of
this sort are undoubtedly helpful, they are insensitive to the face-to-face
interactional contexts in which remediation meetings take place. I needed
practical strategies for how to approach my meetings with students, and
guidance on what to say and do, not a checklist of topics to cover.
Mechanics of the professionalism competency at IUSM
In addition to an academic transcript, each student at IUSM carries a
competency transcript that appears on a combined grade sheet. Failure to
satisfactorily pass the competency curriculum means that a student is not
qualified to graduate from the medical school. Students must demonstrate
competency at three different levels.
To qualify for Level 1 status, students must be able to:
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1. Describe to others the core behavioral abilities of the IUSM competency in professionalism—excellence in humanism, accountability, and
altruism.
2. Understand the acquisition of professional abilities as phronesis
(practical wisdom).
3. Identify professional behaviors ranging from expected (normative) to exemplary, to unprofessional in both the formal and informal
curriculum.
By the time of graduation all students must have achieved Level 2 status and have:
1. Mastered core professionalism skills in teams.
2. Be able to articulate expected professional behaviors under stressful
or challenging circumstances.
3. Demonstrate the core abilities of professionalism in all IUSM-related
interactions with colleagues, faculty, staff, administrators, patients, the
health care team, and others.
Level 3 requires students to select three of the nine competencies to
learn about in greater depth than the standard curriculum. To obtain
Level 3 in Professionalism, students select a topic that will affect their
learning in future stages of their careers, for example, in residency or practice. Working with a faculty mentor, students seeking Level 3 do research
or observe in one or more actual settings, keeping a log of what they
encounter. The log is then used as data for analyzing formal and informal
elements of professionalism in the chosen setting(s). Students submit a
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9. Remediating Professionalism Lapses: Each School an Island?
final report describing their findings and what they have learned about
professionalism that will affect them as they progress in their career.
Managing the professionalism competency:
The Director’s role
The CD’s role consists of three main functions:
1. Developing and maintaining the professionalism curriculum for
medical students across all four years of training.
2. Acting as a resource for students and faculty with concerns about
their own or others’ professional behavior.
3. Serving as the “remediation arm” of the Student Promotions
Committee (SPC) where cases of unprofessional behavior are adjudicated.
In this chapter I will deal primarily with the third function of remediating professionalism concerns and lapses.
Figure 2 illustrates the competency management pathway. A course
director, clerkship director, or faculty member from any of the nine school
of medicine campuses begins the process by entering a competency concern or an isolated deficiency (ID) in the statewide electronic evaluation
system. Competency concerns generally fall into the category of minor
professionalism issues such as appropriate dress for class or clinic, or major lapses such as cheating or failure to show up for clinic or abandoning
other clinical responsibilities. Although there is some variability in how
the criteria for assigning a concern or deficiency are interpreted across
the school’s nine campuses, course or clerkship directors often engage the
CD prior to submitting their assessment. Concerns are handled informally
between the faculty member, the student, and the CD, whereas IDs involve
a formal process that requires a “progress hearing” with SPC to determine
whether the student will be able to remain in school or will be dismissed.
At the same time the concern or ID is registered, the student is notified
of the action being taken. In the case of a concern, the CD is also alerted
and information about the source of the concern is shared with him.
The student is required to meet with the CD to discuss the concern and
plan appropriate steps to deal with it. The CD then relays notes from the
meeting to the course or clerkship director and there is ongoing informal
communication about the student’s progress in dealing with the concern.
Importantly, competency concerns do not appear on the student’s permanent record and thus do not play a role in the Dean’s letter or any other
formal record of the student’s performance during medical school.
An ID automatically triggers a progress hearing before SPC. The committee consists of twenty-four faculty representing basic and clinical
sciences from the nine campuses. Students called for a progress hearing
are required to address the issues raised concerning their professionalism
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and present their explanation for the lapse(s) to the entire committee. In
addition, the student is expected to propose a plan to address how he or
she intends to deal with the deficiencies. A question period follows the
student’s presentation, after which the student is excused and the SPC
votes on whether to dismiss the student or put him or her on probation
with a required remediation.
In cases where SPC votes to dismiss a student, two options are available: the student may request another opportunity to present his or her
case to the committee for a vote; if the second vote fails, he or she can
make a final appeal to the Dean, who can choose to uphold or overturn
SPCs decision.
As an alternative to dismissal, the committee can decide to place a student on academic probation and require successful remediation with the
CD, who also sits on SPC. In this case, the student has an initial meeting
with the CD, who evaluates the seriousness of the lapse, makes an educational assessment/diagnosis of the situation, and negotiates an agreedupon remediation plan. Multiple face-to-face meetings may take place
until the remediation is successfully completed. At that point, the CD
reports back to SPC, which votes to accept or reject the recommendation
to remove the student from academic probation and allow him or her to
continue his or her studies, or to dismiss the student from medical school.
In the nine years that I was the professionalism CD, 105 students came
before SPC for progress hearings. The majority of cases involved a single
instance of a professionalism lapse that varied from falsifying documentation in a procedure log to signing others into lectures and other required
activities. A smaller number of cases involved students who engaged in
dishonest behavior, such as leaving the hospital cafeteria without paying
for a meal. Similarly, there were a small number of more serious cases of
dishonesty that involved cheating on exams or falsifying medical records.
Finally, there was a handful of cases that involved accusations of cyberbullying and stalking. Of the students who came before SPC, six were
deemed unremediable with a recommendation to dismiss from the medical school. Cheating was the most frequent lapse for which dismissal was
recommended. The rest were successfully remediated in a process lasting
from a month to one year.
Case study 1: Responding to a competency concern12
I received a phone call from a basic science course director at a regional
campus asking whether I would meet with a second-year student who, in
the course director’s opinion, “was at risk for problems with professionalism.” He described the student’s behavior in the class he was teaching as
inappropriate and childish, but not yet reaching the level of issuing an ID.
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Prior to, and sometimes during, class the course director reported that the
student would say things like, “This is the stupidest course I’ve ever taken,”
or, “The course instructor doesn’t know what he’s talking about half the
time.” While these comments weren’t particularly hurtful personally, the
director was concerned that the student’s disruptive behavior was a risk
factor that could potentially lead to his being sanctioned or even a losing
privileges or his license to practice at some future point in his career. Since
his own attempts to reach out to the student had been unsuccessful, he
wondered if having the student meet with me would produce a different
result. I readily agreed to meet with the student to discuss the concern.
Todd came into my office full of bravado and bluster. I first asked him
if he knew why he was in my office. He explained that he had a conflict
with the course director and that this meeting was his “punishment.” He
went on to say that the course director had it in for him because he had
been born outside the United States and had been raised in New York City
where things weren’t quite so provincial. He then asserted that he really
didn’t care much about what others thought of him, especially the course
director, as long as he got his work done and didn’t fail any courses.
I listened carefully to Todd, internally testing my own experience of
having grown up in New York City and now having lived in Indiana for
twelve years, with what I was hearing. At the same time I was internally
reviewing what type of remediation exercise might be effective for raising awareness about the importance of professional conduct for a student
who was well-defended and might have impulse control challenges. Rather
than give him a lecture on professionalism, which I thought would be unlikely to have any effect, I suggested that he read Maxine Papadakis’ paper
from the New England Journal13 on the link between practicing physicians who come before state medical boards for unprofessional behavior
and unprofessional behavior while in medical school, and that we talk
again in the next two to three weeks. He reluctantly agreed.
Less than twenty-four hours after our encounter, I got an e-mail from
Todd wondering if we could meet “sooner than two to three weeks.” I happened to have an open hour in my schedule that day and replied, asking
that he come in later that afternoon. Todd came into my office a different
person. He looked exhausted and his eyes were red. I told him that I was
surprised but glad to see him, to which he responded that he had read
the Papadakis article the night before and had been “shocked” to discover
that the article “described me to a ‘T.’ ” Tears formed, and he shared his
fear that there was real danger ahead for him if he continued on the path
he was on. After a long pause, he wondered out loud what he could do to
keep his dream of becoming a physician and serving society alive in the
face of his self-defeating behaviors.
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We talked about various options that might be available, including
psychological counseling. Todd was eager to pursue this course of action
and confessed that he had thought of it a year earlier but rejected the idea
as “weak minded.” After some discussion about what he thought would be
helpful, we settled on a referral to a cognitive-behavioral therapist who
works extensively with medical professionals. I had an opportunity to
observe Todd in his third year in a small group narrative discussion that
is held with students on their medicine rotation. At that point he seemed
to have made a much better adjustment to his environment, those in authority, and his peers. The last contact I had with him was at graduation
in 2011.
Analysis and comment
Three aspects of this case are worth commenting on: the opening gambit, the choice of remediation, and the result. In the literature on clinical
interviewing, eliciting the patient’s perspective before sharing one’s own
allows a clinician to adjust her or his response to the state of knowledge
and point of view of the other rather than making inferences about what
the patient does or does not know and understand.14,15 In this case, eliciting the student’s perspective at the beginning of the encounter allowed me
to gather firsthand information about his perception about why the meeting was being held (as punishment). This opening gambit also allowed
me to compare the student’s point of view and contrast it with what I had
heard from the course director (concern for the student’s well-being).
The fact that the student felt as though he was being punished (persecuted) for his beliefs also provided important information about his
point of view and likely responses to “suggestions,” rather than a formal
remediation program, i.e., the difference between a concern and an ID.
Running through the various options that I had for dealing with a defensive student (similar to working with a “difficult” patient) I chose to simply
present him with the best available data on what is known about professional behavior of medical students and their subsequent risk of coming
before a state medical board for unprofessional behavior and let him draw
his own conclusions. The motivational interviewing literature was helpful
to me here in pointing out that rolling with resistance rather than confronting it is more likely to result in a change in behavior.16 Evidence of
the success of the choice of remediation approach and interviewing style
is shown in the rapidity of the student’s response, his openness to seeking
help to change, and his successful graduation from medical school without
further incident.
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Case 2: A clear-cut case of cheating
Several years ago, the clerkship director for OB/GYN sent me a “heads
up” about one of her students, Albert, who had been struggling during the
last part of the rotation, for no obvious reason, and was observed to have
cheated on the shelf exam. SPC had been notified that the student would
be receiving an ID in professionalism and would be required to make an
appearance before the committee. Parenthetically, cheating is known as a
“capital offense” among many members of the SPC. It is a core precept of
the school’s honor code, and students who do cheat on exams have a high
likelihood of being dismissed if cheating is confirmed. The clerkship director asked me to meet with the student to help him prepare for his SPC
appearance. Before the meeting, I accessed his academic and competency
transcript, which was excellent, and contained several course honors and
no concerns or isolated deficiencies. I also reached out to the competency
director for moral and ethical reasoning, with whom I had shared several
cases, and asked her to be present at the pre-SPC meeting and partner in
the remediation process.
Albert knocked on my office door, came in, sat down, crossed his arms
over his chest, and was silent. My colleague and I asked if he knew why he
was meeting with us and in a very matter-of-fact voice he said, “I cheated
on the OB/GYN shelf exam,” immediately averting his eyes and looking
down, after which an uncomfortable silence ensued. We then shared with
him that we had reviewed his excellent academic record and that in our
experience when incidents like this occurred there was often something
going on in the background that helped explain making poor choices like
cheating. Was that the case here, we asked? Another uncomfortable silence ensued and then with great hesitation Albert told us about receiving
the news of his fiancée’s murder six days before the exam, and his feelings
of helplessness and depression at being thousands of miles away. Through
heaving sobs, he went on to describe his shame at what he had done and
the consequences he would likely face after meeting with SPC.
After expressing our empathy for his loss and telling him that we understood how difficult it must have been for him to cope and to try maintain his studies, we encouraged Albert to share his story at his upcoming
SPC hearing. He replied that he did not think it was possible to tell his
story to twenty-four strangers and that he would sooner leave medical
school than have to share his pain over what had happened. We reminded
him that before this meeting we had been strangers and that he had been
able, albeit with difficulty, to share his story with us. We offered to do a
little bit of coaching and role playing about how to structure the presentation and an assured him that one of us would be there for support. In
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the end he agreed to present his story to SPC. Below is a fragment of the
presentation he read to the committee.
No matter how hard I tried, I couldn’t get rid of the feelings of anger, rage, hopelessness, and guilt along with a constant tightness and chronic pain in my stomach
. . . Toward the end of my OB/GYN clerkship, I found myself avoiding my work,
avoiding people, and spending hours at a time in the restroom crying. I questioned
everything that I ever believed in, including god. For the six days following that
dreadful morning, I had little desire to do anything. As I sat for my OB/GYN exam,
all I could do was think about her. Before I knew it, my time was running out and
I made the poor decision of cheating on my exam, an action that in the past I had
never even considered and for which I am deeply saddened and sorry.
After his presentation there were a few clarifying questions from members of the SPC who then voted unanimously to allow Albert to return to
school after remediating his isolated deficiency. The remediation process
included a recommendation for supportive counseling, doing library research and a paper on the problem of cheating in medical school, grief
and mourning, writing letters of apology, and completing a personal reflection about the importance of asking for help and what his experience
had taught him about professionalism and personal responsibility. Within
minutes of receiving the news that he was going to be able to return to
school after successful remediation Albert sent us an e-mail, part of which
appears below:
I had my meeting today and the SPC committee has voted to allow me to continue
with school! I am extremely happy and feel as if a huge burden has been lifted off
of my shoulders. I would just like to thank both of you from the bottom of my heart
for everything that you have done for me. You made an extremely difficult situation a whole lot easier to handle. Your understanding and friendly nature was like
a breath of fresh air and made me feel extremely comfortable. Once again, thank
you for your help, and support. I am eagerly looking forward to this new beginning.
Thank you once again!
Sincerely,
Albert
After his successful remediation and return to school, I did not hear
from, or about, Albert for almost a year. It was his academic advisor who
called me to discuss his “future.” His advisor told me that Albert had expressed a strong desire to stay at IU for his residency but was convinced
that it would not be possible given the cheating incident and the fact that
it was on his transcript and in his Dean’s letter. Together with my partner
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from the remediation process, and his advisor, we decided to contact the
program director and offer our support for Albert’s application. It turned
out to be unnecessary as the program director had already decided to accept him based on his academic performance and a strong interview that
included a detailed explanation of the incident, his remediation, and what
he had learned about professionalism from the experience. Albert was
accepted into the program where he performed with distinction. Below is
a fragment of Albert’s letter to me on Match Day, just after he learned he
had been accepted to IU.
From: Albert
Dear Dr. Frankel:
I hope all is well. As you probably know, “match day” was today and I was able to
get my first choice . . . at IU! You have been kind and generous with your time, advice, suggestions and guidance and I wanted to make sure that I write and let you
know the results of my match. Thank you so much for all of your help throughout.
I could not have reached this point without your guidance.
Albert
Albert is now in practice in the area, and has firmly established himself
as a valued member of the medical community.
Analysis and comment
Like the first scenario, this case illustrates the importance of applying
sound interviewing techniques, including empathy and support, to elicit
the “narrative thread” of the events for which the student had been cited.
In patient care, the narrative thread allows the interviewer to understand
how clinical facts fit into the larger context of the patient’s life world.17–19
There are clear parallels in clinical medicine, for example, when patient behavior is viewed in isolation (e.g., a patient who fails to take her
medication as prescribed) rather than in the context of their life situation
(mother of four children who has no way to pay for the medication prescribed). The ability of the interviewer to explore the context of behavior
in addition to the behavior itself is an important tool in clinical medicine
that can be applied to remediation scenarios.
In interviewing the medical student before his meeting with SPC there
was no question about the facts; the student himself said straightforwardly, “I cheated on the OB/GYN exam.” However, his affect (flat) and
nonverbal behavior (arms crossed over his chest, averted gaze, looking
down and away, all signs of shame or embarrassment20) were clear signs
that there was more to the narrative thread than his opening statement. It
has been noted in the patient interviewing literature that clinician silence
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in the medical encounter, i.e., acting as a non-anxious presence, often
builds trust and encourages the patient to continue speaking.21–23 In this
case, as uncomfortable as the silence might have felt, it revealed a story
that was both compelling and heartbreaking. Although she was unsure
why, it also matched the clerkship director’s comment that the student
had struggled in the rotation, about the same time that the student reported getting the news about his fiancée’s murder. Once the student’s
“back story” emerged, my colleague and I both used empathy, active
listening, and support—patient interviewing skills known to increase the
likelihood of adherence to recommendations made in clinical care24,25—to
help the student with the decision to tell his story to the SPC.
Evidence of the effectiveness of the pre-SPC meeting and remediation
is demonstrated in having correctly read the student’s non-verbal cues,
using active listening and silence to create space for him to fill in the
background of what happened around the time of the OB/GYN exam, corroboration of the timeline of events by the clerkship director, and genuine
curiosity about the apparent disconnect between the student’s previous
performance and his behavior in the clerkship. In the broader ecology of
his professional formation, the fact that the program director was willing
to invest in a student who had suffered a serious professionalism lapse,
his performance during residency, and subsequent success in practice also
suggests that we made the right decisions in advocating for him.
Case 3: Double jeopardy and faculty responsibility
A third-year student on her medicine rotation received an ID in medicine for having cheated on the final exam. The clerkship director informed
me that the student would be coming before SPC and asked whether I
would meet with her to discuss the situation, which I agreed to do.
In response to my opening question about why she thought we were
meeting, the student acknowledged that it was because she had cheated
on the medicine exam. In providing background to her behavior she described herself as a perfectionist who always put pressure on herself to
perform and said that she wanted to maintain her GPA and get honors
in the rotation because she wanted to go into internal medicine. A few
minutes into the meeting I asked her whether she had shared her situation with others; her parents, in particular. She replied tearfully that she
had told her parents and her fiancé, and that these were two of the most
difficult conversations she had ever had in her life. She went on to say that
she was ashamed of her actions and really wanted to better understand
her behavior. She explained that between the time of the incident and our
meeting, she had sought psychological help and was seeing a psychiatrist twice a week, that she was getting spiritual counseling through her
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church, and had assembled an “accountability committee” with whom she
met weekly. Finally, she said that she was gaining a lot of insight into the
emotional triggers that made her anxious and feel inadequate under stress
and was learning healthy ways of dealing with them.
All in all, it seemed as though the student’s lapse had triggered a cascade of reflection and action that was helping her understand and deal
with stress and the risks of her anxiety overriding her desire/ability to act
professionally. In terms of preparing for her progress hearing with SPC,
we discussed the need for transparency and honesty in taking responsibility for what had happened and the steps she was already taking to address
her problems.
There was a two-month gap between the time that I met with her and
her appearance before SPC. At her progress hearing the student presented
a compelling account of all the steps she was taking, what she had learned
about her response to stress, and healthy new habits and patterns that
she was learning both in therapy and from her accountability committee.
Toward the end of the meeting she put down her written statement, faced
the committee and shared that as a first-year student there had been an
incident in which she was observed to have briefly continued to work on
an exam after the proctor had announced, “pencils down.” She was asked
to meet with the course director to talk about what had happened. The
student said that she had apologized for her action and the course director told her that, ”it wasn’t a big deal,” he wasn’t going to report it, and
that she should follow the proctor’s instructions in the future. The student
cited her sincere desire to get to the root of her “problem” and said that
she wanted to be sure to leave no stone unturned in her quest for “the
truth, the whole, and nothing but the truth.”
When the student was excused from the hearing a long discussion
ensued among the SPC committee members. Most agreed that she was
taking all the right steps to better understand and deal with her triggers,
and that she was thoughtful, sincere, and honest in her presentation. At
the same time, several committee members argued that her admission of
an earlier professionalism lapse, despite the fact that it was minor and was
not officially documented or reported, constituted a “pattern” of behavior
that was unacceptable for a medical student and recommended dismissal.
By a narrow margin the committee voted for dismissal, which was upheld
in the appeals process.
Analysis and comment
This case raises several important questions. First, in my meeting with
the student, many of the recommended steps for an individual who acts
unprofessionally were already being taken voluntarily (confronting the
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problem head-on, psychiatric and spiritual counseling, eagerness to explore and learn about the effect(s) of stress on behavior). In addition, the
student had faced those she loved, her parents and fiancé, and had taken
responsibility for her actions by informing them rather than hiding what
she had done.
From the literature on patient interviewing a key question about highrisk behaviors that one might encounter in highly stigmatized areas such
as marital infidelity, high-risk sex, and alcohol and drug use is to assess
whether there is a pattern of behavior over time.26 In retrospect, I realize
that I failed to ask the student about whether she had experienced anything similar to the episode that occurred during the medicine rotation.
Exploring the student’s history in more depth might have revealed the
previous incident and led to a conversation about the significance of the
instructor’s downplaying the incident and failing to take any action. It
is, of course, speculation to believe that early detection and remediation
would have prevented the student from additional cheating episodes, but
it does seem likely that it would have helped her connect the dots and
perhaps recognize that this behavior contributed to her dismissal from
medical school.
A recently conducted national survey of medical schools’ professionalism remediation approaches by Ziring and colleagues at Drexel College of
Medicine found that the major reasons for failure to adequately address
professionalism lapses were:
1. Faculty reluctance to report
2. Lack of faculty training
3. Unclear policies
4. Remediation ineffective
Factors cited for reluctance to report were: faculty discomfort in determining the seriousness of the problem, the increased workload reporting
creates for them, concern about harming the student’s future, the perceived minor nature of the witnessed lapse, and fear of repercussions.27
These findings echo the theme of physicians protecting one another and
refusing to fail students for unprofessional behavior.28,29 As this case illustrates, my failure to elicit information about the frequency of the behavior
in the pre-SPC meeting coupled with the reluctance of a faculty member
to report the first instance of the student’s questionable professional behavior essentially placed her in double jeopardy for telling the whole truth
to the committee. Sadly, it wound up costing the student her opportunity
to complete her medical training.
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9. Remediating Professionalism Lapses: Each School an Island?
Conclusions
I began this chapter by noting that there has been exponential growth
of interest in professionalism in the last two decades. This is a positive
development as faculty, researchers, and administrators have sought to
define and operationalize the concept. Consensus statements, such as the
Charter on Medical Professionalism have seen simultaneous publication
in multiple journals in the United States and elsewhere.30 Many schools
now have formal professionalism curricula and deans who support the importance of professional formation, as well as faculty who are responsible
for maintaining professional standards and remediating students who
have professionalism lapses.31,32
As interest in professionalism has grown, there has been corresponding
interest in better understanding how different schools approach remediation and identifying best practices that can be translated into regional or
national guidelines. The literature suggests, and my own experience confirms that, at present, each school is an island unto itself and that there
is very little discussion and sharing about what constitutes an effective
program of remediation from school to school. The need to systematically
study this problem using evidence-based approaches has been identified
and is gaining momentum.10 One possible approach to identifying best
practices in remediation would be to use the approach the Accreditation
Council on Graduate Medical Education (ACGME) took in implementing
its six-competency curriculum for all residents.33 When they were introduced in 1999, ACGME “recommended” that all residents become competent in the competencies. It also asserted that evaluation of competencies
was at a formative stage and that they would look to innovative strategies
programs were developing and/or using to identify best practices. Four
years later, in 2002, after having gathered systematic data on the most effective ways of evaluating the recommended competencies, the ACGME
made successful evidence of achievement a requirement for graduation;
not simply a recommended framework that was optional. The same strategy could be used to identify best remediation practices and over time use
them to develop national guidelines with a common core of standards for
evaluating the effectiveness of remediation processes.
Other approaches to reducing the fragmentation of knowledge about
remediation in various medical schools might include collecting and reporting national data on the range of approaches schools take to deal with
professionalism lapses. As well, offering skills-based faculty development
and promoting a national dialogue about guidelines, opportunities, and
challenges might help reduce the isolation of faculty charged with remediation. Finally, asking broader, deeper questions about medical school
admissions practices and tools for identifying students who may be at risk
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for professionalism lapses could make the process of remediation more
proactive than reactive.
The second theme of this chapter focused on the remediation encounter itself and methods drawn from evidence in the literature on patient
interviewing. Faced with a paucity of practical information on how to
conduct remediation encounters with students, I found that evidencebased patient-centered communication skills such as eliciting the patient’s
perspective, using empathy and support, reading non-verbal cues, and
principles of motivational interviewing to be extremely helpful in establishing the narrative thread of events surrounding professional lapses. In
addition, such techniques often provided the deeper understanding that
could not be found or deduced from the student’s file or the clerkship or
course director’s notes. I also found that comparing the story with the
course or clerkship director’s account allowed me to “triangulate” data
from multiple sources that was helpful in confirming or disconfirming
the student’s account.34 Using an evidence-based patient interviewing
approach also permitted me to use a quality improvement framework to
pinpoint errors in my own approach that could, and did, have significant
consequences for at least one student.
The third theme was how we, as faculty, approach the remediation
process. As the opening anecdote suggests, many faculty who do remediation work see it as difficult, challenging, and unrewarding, viewing it
in much the same way as clinicians find working with difficult patients.
Wendy Levinson, in a classic paper entitled “Mining for Gold,” described
how, after years of frustrating encounters, she found something to like
about one of her most difficult patients when she explored the narrative
thread of the patient’s context, and how that understanding led to a positive transformation in their relationship and a shift in loyalty and trust.35
The lesson here is that it is critically important to approach the remediation process with an open mind, to remember that all human beings have
redeeming qualities, no matter how egregious their professional behavior
may have been, and that context matters.6 Whether helping a student
regain his or her footing after a minor professionalism lapse or dealing
with the possibility of dismissal after a major lapse, the goal, just as it is in
patient care, should always be to find ways to be of service.
In closing, I suggest that we would do well to recall that the root word
for remediation is mederi, which in Latin means “to heal.” Together with
the prefix re, which means “again,” we arrive at a definition of remediation
that focuses on strategies and approaches in working with students who
have had professionalism lapses to heal again. As was true in the early
days of the quality assurance movement, when the strategy was to weed
out the bad apples, punish poor performance, and shame and humiliate
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9. Remediating Professionalism Lapses: Each School an Island?
those who didn’t conform to quality standards, many now suggest that
strategies focusing on intrinsic motivation, autonomy, and self-regulation
are much more likely to succeed in producing high-quality results.36,37 So,
too, in approaching remediation encounters. If we re-frame the idea of
punishing students for unprofessional behavior and instead treat it as an
opportunity to help them heal (whether that means a student is dismissed
or allowed to continue his or her medical education) we may find ourselves being more effective and more energized by the task, the process
and the outcomes.
Acknowledgments
Many thanks go to Bud Baldwin, Frederic Hafferty, Thomas Inui, J. Harry (Bud)
Isaacson, Deborah Ziring, and Liz Gaufberg for their careful reading of the manuscript and thoughtful suggestions for how to improve it.
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Strategies for assessment, remediation, and promotion. Pediatrics 2012; 129:
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12. Frankel RM. Professionalism. In: Feldman M, Christensen J. Behavioral
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2007: 424–30.
13. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by
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23. Friedman EH. Generation to Generation: Family Process in Church and
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pass and programmatic assessment enhances recognition of problems with
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11: 29.
29. Dudek NL, Marks MB, Regehr G. Failure to fail: The perspectives of
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35. Levinson W. Mining for gold. J Gen Intern Med 1993: 8: 172.
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Summary
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Chapter 10
Concluding Thoughts
George E. Thibault, MD
T
oday there is more and more interest in professionalism, and more
discussion of it as something that we can and should teach. At the
same time, there are more threats to professionalism and more
examples that run counter to what we would think should be the professional behavior of physicians, other health professionals, and institutions.
So we are at this moment of tension. We actually know more about professionalism, and we have evolved from the point of thinking this is some
kind of intrinsic moral quality to understanding that it is a set of behaviors
that can be taught, can be learned, can be rewarded, and can be incented
or dis-incented. But at the same time, we understand that the other
changes that are going on, such as the commercialization of medicine,
intense competition, resource constraints, and organizational changes that
threaten autonomy all represent a continued threat to professionalism.
I suggest three ways I think we should be broadening the discussion for
us as educators and leaders. First, the professionalism discussions should
be about how we raise the consciousness and behavior of all students and
trainees (not just those who need remediation). Second, we need to think
about professionalism in the context of the organizations in which we all
function and how these organizations can have positive or negative influences on professional behavior. And third, we should be thinking about an
inter-professional professionalism that involves the other health professions that are our partners in caring and teaching.
I want to offer a definition of professionalism provided by U.S. Supreme
Court Judge Louis Brandeis a century ago. Brandeis identified three
characteristics of the learned professions. First, a learned profession is in
possession of a special set of knowledge and skills that it is responsible
for mastering, for improving, and for passing on to the next generation.
Second, a learned profession puts others’ interests ahead of its own. Third,
a learned profession is self-regulating.
This has been a helpful framework for me, and I think I can link most
of the behaviors we are seeking to teach and measure to these three principles. Reductionism to the particular behaviors is important to define a
curriculum and an assessment system, but I believe it is important that
this be done within a higher framework.
There are two important parts to realizing that professionalism does
not happen in a vacuum: one has to do with the entire educational environment and the second has to do with the relationship between education and health care delivery.
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Structures to help us monitor and correct behaviors will not mean
anything if they are not consistent with everything else that we say and
do from day one on. It does matter what we teach in the curriculum, and
it does matter how we structure the curriculum. But it also does matter
how we form relationships between faculty and students and how we set
examples and model behaviors. Talk about the resistance to “forward feedback” reminds me of how broken our system is. Because we are so worried
that students and faculty will have nothing other than very casual encounters, we don’t believe that constructive feedback will or can be given. If we
do not do something about that, then we are not being consistent when
we say we are going to put a system in place to remediate unprofessional
behavior. The whole structure and environment have to support what it is
we want to accomplish. Understanding there are a lot of impediments, we
have a responsibility to deal with the things that are getting in the way of
our goals. Unless we do that, then the best measurement and remediation
system in the world is not going to work. We have to show that we really
care, and that we are fixing things that don’t work in our educational system. We must be consistent in how we set up our whole educational process so that it fosters continuity of relationships and models the behaviors
we want our students to learn.
The second part of this not occurring in a vacuum is that the medical
school and the medical students are part of a larger health care system.
While the medical school in most instances does not control the rest
of that system, it must interact with it. We have a responsibility to our
students and to our profession to do a better job at building the bridges
between the educational system and the delivery system. We will not be
successful in our professionalism goals unless we do that. That is hard
work, and it is frustrating at times. We often feel like we live in different
worlds and cultures, but we have got to bridge that gap or we are not going
to succeed. We need to articulate how the educational goals connect with
the rest of the health care system. We need to make clear how the rest
of the health care system shares the responsibility for creating the ideal
educational environment for our next generation of health professionals.
We will not succeed unless we build those bridges with others. Education
needs to be informed by the needs of the public and the changing delivery
system; and the changing delivery system must embrace and incorporate
the educational mission.
The last observation I would make is that this is about culture change.
Some have compared professionalism to the quality and patient safety
movement. Yes, it is a professional responsibility not to harm patients
and to constantly improve, but professionalism is more than that. It is
also a professional responsibility to work with and respect other health
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10. Concluding Thoughts
professionals and acknowledge when they know more than we do. It also
is a professional responsibility to assure one’s own competency and the
competency of the next generation of our profession. It also is our professional responsibility to work with other health professions in setting the
standards for those competencies. And we do all of this because we exist
as professionals to serve the public, and we earn our special privileges
only if we do that. So we are back to the Brandeis definition of professionalism, but with a realization that this professionalism is not a solo
activity. To accomplish it (and teach it) we need to effect a culture change
in which we break down the silos between the professions and function
in a non-hierarchical way; we must become truly patient-centered rather
than profession-centric; we must focus on the needs of the community in
designing both education and care; and we must create the kind of caring
and collaborative environment in which our students see professionalism
modeled and receive the constructive feedback they deserve.
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Chapter 11
Improving Professionalism in Medicine:
What Have We Learned?
Sheryl A. Pfeil, MD
T
he preceding chapters, authored by diverse experts in medical
professionalism, bring valuable information and underscore an important challenge facing our profession: How do we hold ourselves
to the highest standards of professional conduct under all circumstances?
And what do we do—what should we do—when we fall short?
George Thibault reminds us, in his concluding remarks following the
2013 AΩA summit, that professionalism is neither an intrinsic moral quality nor a set of attributes and beliefs, but a set of behaviors that can be
taught, learned, rewarded, incentivized, and disincentivized (see Chapter
10). As such, professionalism encompasses the standards of conduct and
the observable behaviors that stem from our underlying belief system.
Self-regulation is fundamental to any profession, but particularly so to
medicine, built as it is on the covenant of trust the profession has with
patients and society.
Professionalism is a core competency for all physicians. All medical
professionals, whether established or newly entering the profession, need
to embrace the values of medical professionalism and demonstrate the
aptitude and commitment to behave professionally. It is true that many
things in the day-to-day world of health care can stress the behavior of
even the most professional physicians. These may include system pressures such as resource constraints, productivity and efficiency expectations, and organizational challenges. There may be value conflicts, patient
conflicts, Maslow conflicts. Furthermore, the rules of professionalism are
contextual, and the professional response to complex situations may be
nuanced (see Chapter 1). But these acknowledged complexities do not diminish the imperative for us, as a profession, to hold ourselves accountable
for sustaining professionalism.
If ever there were a case for lifelong learning, sustaining professionalism
would be it. Even the most experienced practitioner must be continuously
self-vigilant as new challenges, new systems, and new expectations arise.
We need to consciously engage in and model professional behaviors in our
interactions with patients, team members, and the health system. Medical
students and other learners are particularly vulnerable—they learn what
they see and experience in the “hidden curriculum.” When those of us who
should be positive role models demonstrate disruptive behaviors such as
intimidation, making disparaging remarks about patients or other team
members, or specialty bashing, and—worse yet—when we collectively and
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systematically tolerate these behaviors, we threaten our culture of professionalism and send a dangerous message to learners (see Chapter 1). But
when we model professional behaviors, eschew cronyism, and embrace a
culture of respect and collegiality, we create a positive professional culture
that “raises all boats.”
Professionalism lapses and remediation:
Does one size fit all?
A critical component of professionalism is a commitment to self and
group regulation and accountability. We need to respond or intervene
when a lapse is identified. We have been made keenly aware of the importance of identifying professionalism shortcomings among students
by Papadakis et al., who in a 2004 report linked professionalism lapses
in medical school to future disciplinary action by a medical licensing
board.1,2 There is a growing understanding that the formation of professional identity is a developmental and dynamic process; learners will
inevitably make mistakes and will require guidance or remediation before
becoming full professionals. But remediation has little value unless it
predictably leads to improvement, and little is known about what the best
practices are or should be. What is the right thing to do? How should we
assess improvement? How long should we follow student progress? Should
information about student lapses feed forward to future evaluators?
In response to these types of questions, Ziring et al. surveyed medical schools in the United States and Canada to learn about their policies
and procedures for identifying and remediating professionalism lapses
among students (see Chapter 3). Most schools have written policies and
procedures regarding medical student professionalism lapses, including
descriptions of expectations, mechanisms for reporting, and potential
consequences. Using the Papadakis four-category behavioral classification of professionalism lapses (see Chapter 1), the most common reported
categories of professionalism lapses were: 1) lapses in responsibility (e.g.,
late or absent for assigned responsibilities, missing deadlines, unreliable);
followed by 2) lapses related to the health care environment (e.g., testing
irregularities such as cheating or plagiarism, falsifying data or not being
respectful to members of the health care team); and 3) lapses related to
diminished capacity for self-improvement (e.g., arrogant, hostile, or defensive behavior); with only a few schools identifying frequent concerns in
the domain of 4) lapses around impaired relationships with patients (e.g.,
poor rapport, being insensitive to patients’ needs).
Some of the remediation strategies included mandated mental health
evaluation/treatment, completion of a professionalism assignment such
as directed reading and reflective writing, assigning a professionalism
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11. Improving Professionalism in Medicine: What Have We Learned?
mentor, stress/anger management, and repeating part or all of a course.
Some schools issued a behavioral or remediation “contract.” Some schools
took more of a punitive stance and others took a more developmental approach. Regardless of the strategy, the criteria for successful remediation
were not well defined.
The feeding forward of information about a student’s lapses to the next
clerkship or assignment was also inconsistent, and sometimes depended
on the stage of training and type of lapse. While forward feeding was
sometimes used to track performance and guide students, there was also
concern about its potential to create bias.
When asked what was working well, schools identified themes such
as catching minor offenses early, emphasizing professionalism schoolwide, focusing on helping rather than punishing students, and assuring
transparency and communication of expectations and consequences. The
major weaknesses included reluctance to report by both faculty and students, the lack of faculty training, unclear policies, and ineffectiveness of
remediation strategies (see Chapter 3).
Lucey adds additional insight about why faculty who witness unprofessional behavior may be reluctant to report it. She describes the behaviors
of denial (it wasn’t unprofessional), discounting (it was unprofessional but
it was warranted), or distancing (it was unprofessional but let’s just move
on).3 Lucey also adds that failing to correct a professionalism lapse may
be because faculty lack confidence in their ability to intervene successfully
or because they are concerned that a report to an authority could result in
sanctions disproportionate to the severity of the witnessed behavior (see
Chapter 2).
In Frankel’s detailed description of the tiered professionalism competency program at Indiana University School of Medicine, he describes a
two-pathway approach to managing professionalism lapses (see Chapter
9). Course directors or faculty members may enter a “competency concern” or “isolated deficiency.” Competency concerns are handled informally between the faculty member, the student, and the Competency
Director; they do not appear on the student’s permanent record and do
not play a role in the MSPE (Dean’s letter). On the other hand, isolated
deficiencies automatically trigger a progress hearing before the Student
Promotions Committee. This two-pathway approach allows consideration
of the severity of the lapse, and provides a mechanism for reporting with
limited adverse consequences when the infraction is less serious.
Across the board, the considerations that are most often cited as relevant in addressing and remediating professionalism lapses include the
gradation or severity of the offense, whether there is a pattern of professionalism lapses (recidivism), and the stage of the learner. While some
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institutions have separate processes for addressing medical student and
physician professionalism lapses, other institutions assume a more holistic, medical center–wide or even interprofessional approach. Indeed,
as the ways that we provide health care and are reimbursed for doing so
change, it will be imperative to address the professionalism competencies of multidisciplinary and interprofessional groups and the individuals
working within them. Payment models will increasingly focus on care coordination, requiring hospitals and physician providers to work together.
Reimbursement will be increasingly focused on value, quality, and outcomes that necessitate interdisciplinary care collaboration and resource
sharing. As we move to more value-driven, accountable care, the ways that
we deliver care and, consequently, our professional behavior, will become
more interdisciplinary, more interprofessional, and more interconnected.
Professional behaviors will be demonstrated and judged in new dimensions and contexts, across the continuum of learning stages and across the
spectrum of health provider roles and relationships.
What is working?
As we seek to acknowledge, prevent, and remedy the problems of
professionalism within medicine, it is helpful to look at “best practices”
in health care systems nationwide. What is working, and why? Is anything working? If so, is it generalizable? Hickson and Cooper in Chapter
7 described the Vanderbilt approach to promoting professionalism. This
exemplar model was developed with the precepts that there must be
leadership commitment to hold all members of the group accountable
for professional behavior, as well as support by people, processes, and
technology to provide an infrastructure to address lapses in professionalism. Core principles of the Vanderbilt model include fairness and justice,
“certainty” of data, a commitment to provide individuals the opportunity
through feedback to develop personal insight, and a goal of restoration,
allowing the individual to regain the honor of being a professional. A hallmark of the Vanderbilt model is the professional accountability pyramid.
Beginning at the lowest tier, a single unprofessional incident is addressed
by an informal, “cup of coffee” intervention, an apparent pattern of unprofessional behavior is addressed by a level 1 “awareness” intervention, a
persistent pattern necessitates a level 2 “guided” intervention and refractory unprofessional behavior may lead to disciplinary action. Standards of
practice and conduct are enforced consistently and equitably, regardless
of the individual’s stature or value to the organization, and there is clear
protection of the reporter from retaliation.
As described by Shapiro in Chapter 5, the Brigham and Women’s
Hospital Center for Professionalism and Peer Support (CPPS) was created
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to support and encourage a culture of accountability, trust, and mutual
respect in which physicians feel supported and valued. When a concern
is brought forth, the CPPS staff first meets with the reporter, then speaks
with others to gather multisource data before bringing the concern to the
individual’s supervisory physician. The center staff and supervisory physician meet with the focus person to give frame-based feedback. The goal is
to focus on the behavior, explain that the behavior needs to stop, and describe the expected behavior going forward, with the intent of motivating
the individual to change his or her behavior. Does the process work? Since
2009, of 242 individual physicians about whom concerns were raised and
10 instances of team dysfunction, there has been retraction (by departure
or demotion) of only 31 physicians. CPPS acknowledges the need for unwavering institutional support of the process. They also recognize that
people perform best in a supportive environment and have developed
various peer support programs to accomplish this goal.
As Saavedra reports in Chapter 6, the University of Texas Medical
Branch (UTMB) has developed a mix of programs aimed at understanding, influencing, promoting, and monitoring an enterprise-wide
culture of interprofessional professionalism. UTMB considers professionalism a standard of conduct and a strategic objective. This multidisciplinary approach is led by a Professionalism Committee. The UTMB
Professionalism Charter extends to all faculty, staff, and students, and its
mandate is “to hold every member of the UTMB community accountable
for acting with integrity, compassion and respect towards one another
and those we serve.” The Charter is comprised of thirteen commitments
that address such specifics as professional competence, honesty, conflicts
of interest, and access to health care. Students have developed an honor
pledge shared by students in all four schools, and UTMB has created a
number of proactive programs to support these commitments, including
interprofessional education courses, programs to recognize exemplary
models of professional behavior, and a professionalism summit. To maintain the professional education climate, the school has an online mechanism for students to report unprofessional behavior or mistreatment.
Concerns about student professionalism lapses are addressed by an Early
Concern Note (ECN), an informal intervention separate from the student’s academic record that remains confidential between the student and
the associate dean unless a student receives three or more ECNs during
matriculation. Does this program work? A laudable feature of the UTMB
program is that a series of student, employee, and patient surveys are used
to promote and measure the effectiveness of the program over time and
across multiple stakeholders. UTMB reports the survey data and uses the
results for constructive improvement. The UTMB program is an example
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of a system-wide approach to address and sustain health care professionalism by a culture of shared values and interdisciplinary collaboration.
The Vanderbilt, Brigham and Women’s, and UTMB models represent
examples of well-established programs in professionalism monitoring and
remediation. Yet for these programs and others, there is limited evidence,
beyond feasibility, of their success. Outcome studies over the long term
after remediation remain critical. Are we effecting long-term behavior
change on the part of individuals, and are we positively influencing systems to facilitate better care? Is there an eventual payoff for the public
from the effort, cost, and effect on clinicians of these strategies? These are
the critical questions that beg for future outcome analyses.
Bringing other models to bear on the problem of
professionalism
Beyond the exemplars described above, what other system models
might help us effectively address professionalism shortcomings? Do we
have evaluative processes and change models used in other contexts that
might be useful in improving medical professionalism and professional
behaviors?
In 2008, the Joint Commission issued a sentinel event alert statement
that underscored the direct relationship between unprofessional behavior
and quality of patient care:
Intimidating and disruptive behaviors can foster medical errors, contribute to
poor patient satisfaction and to preventable adverse outcomes, increase the cost
of care, and cause qualified clinicians, administrators and managers to seek new
positions in more professional environments. Safety and quality of patient care is
dependent on teamwork, communication, and a collaborative work environment.
To assure quality and to promote a culture of safety, health care organizations must
address the problem of behaviors that threaten the performance of the health care
team.4
This direct connection between behaviors and patient outcomes begs
the question of whether professionalism lapses should be considered
analogous to—or a form of—medical error.
In Chapter 2 of this monograph, Lucey frames the challenge of sustaining professionalism as a complex adaptive problem, and she describes the
similarities between medical errors and professionalism lapses, noting
that at times, “those who we otherwise consider to be good physicians . . .
commit professionalism lapses [resulting from] a temporary mismatch
between the individual’s knowledge, judgment, or skill and the complexity of the situation in which they find themselves.” p14 Like medical errors,
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professionalism lapses vary in severity and occur predictably (e.g., when
individuals are stressed, the situations are highly charged, and controversy
is present). Lucey points out that the systems in which we care for patients
and educate our learners can either help us sustain our professional values
and behaviors or render us susceptible to failure. Acknowledging the role
of the system and the environment allows us to understand the complexity of professionalism lapses and to employ a root cause analysis model to
devise strategies to help us address or prevent lapses. Lucey also explores
the concept of “latent errors”—decisions about how health care systems
are run that may predispose to “latent lapses”—when the system fails to
protect the vulnerable patient from the fallible physician. She challenges
us to view professionalism not as a dichotomous character trait but as a
complex and renewable competency, and to approach professionalism
from the perspective that even those most deeply committed to practicing
the values of professionalism will sometimes be challenged by circumstances and environments that are trying and arduous. Lucey advocates
teaching skills of “professionalism resiliency,” shaping health care delivery
systems to support a culture of professionalism, and championing positive
examples.
If we indeed view professionalism as a complex multidimensional competency and a developmental process, what lessons can we bring from
other competency-based education, such as the development of clinical
skills? It is clear that in the domain of professionalism competency we
must develop similarly robust ways to identify low performers, accurately
describe the deficits, design a remediation program, and then measure the
outcomes. Because professionalism competency is vital for both learners
and the learners’ future patients, Chang in Chapter 8 emphasizes the importance of early identification of deficits and the relevance of comparing
the learner’s performance with expected milestones using objective measures, just as would routinely be done for medical knowledge and clinical
skills.
Finally, the measurement of outcomes after remediation remains a
challenging task in every domain, but especially in professionalism, as
Chang notes. Do we aim to change the learner’s attitude, behavior, or
both? How do we systematically document performance, and what opportunities do we have for reassessment other than absence of negative
reports? What if the improvement is not consistent across settings or
over time? These and other questions remind us of what still needs to be
learned about remediation.
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Concluding remarks
So what is the take home message? We have heard from experts who
represent widespread geographic and system diversity and who bring
perspectives about the continuum from student learner to senior faculty.
How do we get to where we want to be? How do we achieve and sustain
the highest level of professionalism in all of our systems for the benefit
and protection of patients, learners, and practitioners alike? How do we
remain ready to meet the next new challenge in professionalism and
continue to reach for innovative approaches? The models that have been
presented focus not just on the individual, but on the culture and systems
that underlie our performance within a complex environment.
When we consider the remediation of professionalism—or perhaps
more euphemistically the improvement of professionalism—five principles help frame our call to action:
1. Professional identity formation and professionalism competency,
while inextricable, are not the same. Professional identity is the self or
being that develops as the “characteristics, values, and norms of the
medical profession are internalized, resulting in an individual thinking,
acting and feeling like a physician.” 5 Professionalism, on the other hand,
is a behavior that is observable, measureable, and—by its nature—modifiable. Professionalism is a complex competency6 that is contextual, dynamic, and both individual and shared. Those who observe and evaluate
professionalism include attending physicians, patients, co-workers, and
students. Because feedback about professionalism comes from multiple
sources and by varied means, ranging from incident reports to formal
evaluations, we need a better system to collect and synthesize this information so that we can intervene most effectively.
2. We need to hold individuals accountable for their behavior. When
professional lapses occur, they negatively affect patients, colleagues, students, and other members of the health care team. Worse yet, students
learn what they see, and unprofessional behavior that is tolerated, ignored,
or allowed to continue is likely to be emulated. Standards of professionalism need to be upheld unconditionally regardless of an individual’s seniority or institutional stature. And to respond appropriately as observers, we
need both to be able to recognize lapses in professionalism when we see
and experience them and to have the resources and systems in place to
respond appropriately. Interventions need to be step-wise and specific to
the lapse.
3. We need to hold systems accountable. Health care systems substantially influence the behavior of physicians and others who practice
within them and can thus directly impact patients, employees, and the
larger community. We need to recognize and raise awareness of the
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environmental barriers—resource constraints, productivity pressures,
competing expectations, conflicting goals, and other system pressures—
that make it more difficult to align our behavior with our professional
standards. And we need to hold health care organizations accountable for
competencies of service, respect, fairness, integrity, accountability, and
mindfulness.7
4. Remediation of professionalism lapses needs to be foremost formative rather than punitive. Unprofessional behaviors in well-intentioned
physicians often occur when they lack the knowledge, skills, adaptability,
self-awareness, or personal resources to manage the challenges they face.
We have an obligation to help physicians understand how their unprofessional behaviors are perceived and how they affect patients and the health
care team, as well as to explore root causes and develop plans to prevent
future lapses. We can further support change by providing ongoing feedback and reinforcement of positive behaviors.
5. We need to study the outcomes of what we are doing. This, more
than anything, is our imperative. We need to evaluate whether our interventions are effective over the long term. What strategies are best for
each learner level, type of lapse, or circumstance? The task of improving
professionalism is hard work, and we need to gather information to guide
and refine our efforts.
The secret to achieving our goal of improving professionalism lies in
understanding its complexity and being willing to accept that professionalism is a universal, dynamic, renewable, and contextual competency. We
need to tackle this head on, bringing our combined energies, ingenuity,
creativity, and focus to bear on this issue. There is no greater threat to
our profession than our own professionalism, and no greater opportunity
to sustain the worth of what we do. Assuring professionalism in the way
we deliver health care is the single most important call to action, and one
at which we must succeed if we are to maintain the sacrosanct covenant
of public trust and demonstrate universally that we can live up to the
promises and expectations of competency and ethical values—that we are
indeed “worthy to serve the suffering.”
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behavior in medical school is associated with subsequent disciplinary action by a
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2673–82.
3. Mizrahi T. Managing medical mistakes: Ideology, insularity and
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accountability among internists-in-training. Soc Sci Med 1984; 19: 135–46.
4. Joint Commission on Accreditation of Health Care Organizations. Sentinel
Event Alert 40: Behaviors that Undermine a Culture of Safety. Oakbrook Terrace
(IL): Joint Commission on Accreditation of Health Care Organizations 2008 Jul 9;
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