Alpha Omega Alpha Honor Medical Society

Medical Professionalism: Best Practices

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INTRODUCTION

Chapter 3. Current Practices in Remediating Medical Students with Professionalism Lapses

Deborah Ziring, MD, Suely Grosseman, MD, PhD, and Dennis Novack, MD

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.

Although 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

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 closed-ended questions. Questions addressed the following four areas:

  1. Professionalism policies
  2. Identification of students with lapses
  3. Administrative response to 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 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, 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 Determines action after lapse Devises remediation Oversees remediation Assesses outcome of 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 incident-based reporting, items on routine student evaluations, a separate professionalism course with grade, formal peer assessment, and anonymous reporting.

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.

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.

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 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.

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 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 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.”

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.

“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 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 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 well-defined 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 sub­optimal 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 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/2015-16-functions-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 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/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 2008; 83: 800.
  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.

 

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

  1. 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

  2. What are the three most common unprofessional behaviors identified at your school?
  3. 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.
    1. Preclinical years:
      1. 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)?
      2. Routine Periodic Evaluation of Professionalism: Types of collection mechanisms
        Do you use standard or routine course evaluations that include professionalism information?
        1. Does not use
        2. Use for ALL courses
        3. 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:
    2. Clinical years:
      1. 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)?
      2. Routine Periodic Evaluation of Professionalism: Types of collection mechanisms
        Do you use standard or routine course evaluations that include professionalism information?
        1. Does not use
        2. Use for ALL courses
        3. 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:
      3. Do other individuals, such as house staff, patients, and/or nurses, provide feedback about professionalism of students? How?
      4. Is the process different when a student is on an away elective?
    3. 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

  1. When unprofessional behavior is identified and requires a response beyond immediate feedback, who is initially notified?
    1. Course or clerkship director
    2. Student Affairs dean
    3. Faculty Director of Professionalism Program
    4. Dean
    5. Other
  2. 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?
    1. Course or clerkship director
    2. Student Affairs dean
    3. Faculty Director of Professionalism Program
    4. Dean
    5. Other
  3. Regarding the response to unprofessional behavior, please explain the role of:
    1. Honor Court/Student Professional Conduct Committee
    2. Promotions Committee
    3. Committee of Faculty or Administrators convened specifically to review unprofessional conduct
    4. Student Affairs Dean
    5. Other Individuals or Groups (please identify by title)
  4. 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

  1. When a student is referred to remediation, who devises the remediation?
    1. Course or clerkship director
    2. Student Affairs dean
    3. Faculty Director of Professionalism Program
    4. Dean
    5. Other
  2. Who oversees the remediation?
    1. Course or clerkship director
    2. Student Affairs dean
    3. Faculty Director of Professionalism Program
    4. Dean
    5. Other
  3. Who assesses the outcome of the remediation?
    1. Course or clerkship director
    2. Student Affairs dean
    3. Faculty Director of Professionalism Program
    4. Dean
    5. Other
      Explanation:
  4. What strategies are utilized for remediation of unprofessional behaviors?
    1. Repeat course/clerkship
    2. Repeat course/clerkship with faculty supervision regarding professionalism deficit
    3. Mandated professionalism mentor:
      Who is assigned?
      How often do they meet?
    4. Stress management counseling
    5. Remediation curriculum or assignment
    6. Mandated mental health evaluation/treatment
    7. Community Service
    8. Other:
      Explanation/Please provide an example so we can better understand your process.
  5. 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:
  6. If a student has a significant professionalism incident, is there a standard, monitoring process moving forward?
    __Yes __No
    If yes, please describe:
  7. What are some examples of the least serious unprofessional behaviors that require remediation?
  8. What are some examples of the most serious unprofessional behaviors that require remediation?

  9. What is working well with your current professionalism remediation strategies and what do you see not working so well?

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?

 

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Updated on May 14, 2015.


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