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Chapter 1. Introduction
Maxine A. Papadakis, MD
The 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 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 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 Mini-evaluation 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 (twenty-six 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 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 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.
- 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.
- 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.
- 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.
- Lesser CS, Lucey CR, Egener B, et al. A behavioral and systems view of professionalism. JAMA 2010; 304: 2732–37.
- Barzansky B, Etzel SI. Medical schools in the United States, 2011–2012. JAMA 2012; 308: 2257–63.
- Cruess R, McIlroy JH, Cruess S, et al. The Professionalism Mini-evaluation Exercise: A preliminary investigation. Acad Med 2006; 81 (10 Suppl): S74–78.
- McLachlan JC, Finn G, Macnaughton J. The conscientiousness index: A novel tool to explore students’ professionalism. Acad Med 2009; 84: 559–65.
- 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.
- 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.
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Updated on May 14, 2015.
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