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Chapter 11. Improving Professionalism in Medicine: What Have We Learned?
Sheryl A. Pfeil, MD
The 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 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 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 school-wide, 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 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 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 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, 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.
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:
- 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.
- 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.
- 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 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
- 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.
- 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.”
- 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.
- Mizrahi T. Managing medical mistakes: Ideology, insularity and accountability among internists-in-training. Soc Sci Med 1984; 19: 135–46.
- 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.
- Cruess RL, Cruess SR, Boudreau JD, et al. Reframing medical education to support professional identity formation. Acad Med 2014; 89: 1446–51.
- 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.
- Egener B, McDonald W, Rosof B, Gullen D. Perspective: Organizational professionalism: Relevant competencies and behaviors. Acad Med 2012; 87: 668–74.
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Updated on May 15, 2015.