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Chapter 4. Review of Current Models for Remediation of
Sheryl A. Pfeil, MD, and Douglas S. Paauw, MD
Professionalism is one of the most basic tenets of medical practice. It is one of the ACGME core competencies and an expectation of every medical student, resident, and practicing physician. Professionalism encompasses core professional beliefs and values, and there is an assumption that all persons entering the medical profession should have the aptitude and commitment to behave in a manner consistent with this value climate.1 The belief that the medical profession should be held accountable to standards that are developed, declared, and enforced by the profession itself is also a promise to society.2,3
The authors of the 2010 Carnegie report assert that professional identity formation—the development of professional values, actions, and aspirations—should be one of the four pillars of medical education.4 Despite widespread agreement regarding the critical importance of teaching professionalism in the medical curriculum and the importance of addressing unprofessional behaviors, there has been no clear consensus on best practices with regard to the assessment of competency and remediation of below-standard performance.1,5–8 On an individual level, professionalism is not a dichotomous trait but rather a behavioral response that can be challenged by stressors and competing professional priorities.9–11 Furthermore, lapses can be a part of learning, and learners require education and guidance before becoming full professionals.1
Call to action
The expert participants in the 2011 Alpha Omega Alpha-sponsored think tank on medical professionalism focused on interventions and remediation of professionalism lapses, with a consensus call to gather existing practices on interventions and remediation that are used for medical students, residents, faculty, and practicing physicians, and to evaluate existing remediation practices via formal research.1 While data is still lacking on best practices for the remediation of professionalism, there is general agreement that remediation should be profession-led, that it should involve a diagnosis of the problem(s) and development of a learning plan, that instruction and remediation activities need to occur, and that some form of reassessment or follow up is needed to evaluate the adequacy of the intervention.12–14 In this section, we outline some of the reported practices for remediation of unprofessional behaviors with examples from the published literature and from the authors’ experiences.
Programs for remediation of unprofessional behavior
The Vanderbilt University School of Medicine has established an approach for identifying, measuring, and addressing unprofessional behaviors.15 The Vanderbilt model is graduated, based on the severity of the unprofessional behavior, with physician behaviors and corresponding interventions stepped as a pyramid. The base of the pyramid includes the vast majority of physicians who consistently behave in a professional manner. Ascending up the pyramid, the next group encompasses those physicians who have a single unprofessional incident. These incidents are addressed by a conversation that serves as an informal intervention. The next step up the pyramid is when unprofessional or disruptive behaviors recur as an apparent pattern. This pattern is addressed by an awareness intervention that involves compiling and sharing data that sets the physician apart from his or her peers. Most physicians respond and make appropriate behavioral adjustments. However, a small proportion of professionals seem unable or unwilling to respond to an awareness intervention and develop a persistent pattern of unprofessional behavior. These physicians require an authority intervention, with an improvement and evaluation plan and ongoing accountability. Finally, there are the small numbers of physicians at the tip of the pyramid who, failing to respond to interventions, require disciplinary action and restriction or termination of privileges and appropriate reporting to other entities. Other key aspects of the Vanderbilt program include a supportive institutional infrastructure that involves leadership commitment to addressing unprofessional behaviors, available surveillance tools, and training and resources for addressing unprofessional behavior.
The Center for Professionalism and Peer Support at the Brigham and Women’s Hospital (CPPS) is another exemplar program for addressing unprofessional behavior.16 The CPPS does hear concerns about medical student unprofessional behavior, but most reported concerns are about physicians. The CPPS process, as previously outlined by Papadakis et al.,1 involves five steps. The first two steps are the reporting of the concern to the CPPS and the investigation of the concern. The reporting conversation is confidential, and the reporter is allowed to choose how to move forward with the complaint, usually allowing the CPPS to further investigate the concern. Multisource interviews are conducted to determine the validity of the complaint and to obtain comprehensive input about the behavior concern. The third step is a feedback conversation with the individual of concern. The CPPS investigator and the individual’s supervising physician meet with the individual to present feedback and to hear the individual’s viewpoint. The focus is on the behavior, and there is a clear expectation for behavioral change. A caring but straightforward approach is used, acknowledging the frequent need for a combination of personal responsibility for behavior change and system change to facilitate a less stressful environment. The specific behaviors that need improvement are summarized, and information is provided as to how the institution will follow up to assure that the behavioral changes have occurred. Resources such as personal coaching or educational resources are offered at this juncture, but the individual decides how he or she can best facilitate the behavior change.
If subsequent lapses occur, the process moves to the fourth step. At this step, the institutional administration becomes involved, with a team that may include a member of the CPPS, the chief medical officer, the department chair, or program director. Members of the administration team meet with the individual to inform the person that the unprofessional behavior has continued and that his or her institutional appointment and employment are at risk. Interventions such as personal coaching, behavioral programs, or an external evaluation may be required. The fifth step in the process involves completing the loop by communicating with the reporter of the complaint. This communication is balanced by the competing need to maintain the privacy of the individual about whom the concerns were raised. The reporter is informed that the institution is addressing the concerns and that he or she should inform the institution should the behavior continue or should there be retaliation. This process demonstrates that professionalism concerns are taken seriously by the institution, and that the value of professional behavior and culture of professionalism are supported.1
Both the Vanderbilt University disruptive behavior pyramid and the Brigham and Women’s Hospital program predominantly focus on physician behavior. Along those same lines, Case Western Reserve University has developed a remedial continuing medical education course (Intensive Course in Medical Ethics, Boundaries, and Professionalism) for physicians that was designed in consultation with licensure agencies to address the needs of physicians with problems in the areas of ethics and boundaries.17 The course includes multiple teaching and assessment methods, such as case discussions, knowledge tests, skills practice, and reflective essays based on the participant’s ethical lapse. During a seven-year period from 2005 through 2012 the course had 358 participants.
The University of Colorado School of Medicine recently published results from its comprehensive remediation program18 that is utilized by medical students, trainees, and attending physicians, with nearly half of participants being medical students. The remediation program is available to learners having a variety of deficits, including deficits in medical knowledge and clinical reasoning and other areas, as well as in professionalism. During a six-year period from 2006 through 2012, 151 learners were referred. An analysis of the program showed that the prevalence of professionalism deficits increased as training level increased. Of note, most learners had more than one deficit. A remediation specialist conducts a semi-structured intake interview with each participant. A “Success Team,” comprised of the remediation specialist and learner, and possibly others (e.g., faculty from the referring clerkship, a mental health professional, the student affairs dean), reviews the learner’s academic record, direct observations, and other relevant material, and then creates and implements a remediation plan to correct the identified deficit. The plan includes deliberate practice, regular feedback, and an opportunity for the learner to reflect on his or her performance. Reassessments, assigned by the Success Team, are performed by faculty members who are unaware of the learner’s remediation status. They may consist of such things as end-of-rotation assessments, direct observations, multiple-choice question exams, or standardized patient encounters. The course, clerkship, or program director receives the results and makes the ultimate determination regarding success of the remediation efforts. Within the University of Colorado program, poor professionalism was the only predictor of probationary status. The program reports an overall remediation success rate of ninety percent, with success meaning that referred learners graduated from their training programs, were in good academic standing, transferred to another program and graduated, or were practicing medicine without restrictions.
While approaches to unprofessional behavior are similar across the continuum of practice from medical student to practicing physician, there are some unique aspects of addressing unprofessionalism at each training level with regard to the types and spectrum of unprofessional behavior, the types of resources that are applicable and available for remediation, and the interventions that are most pertinent to each level of medical training and practice. Focusing specifically on remediation of medical student professionalism, the Ohio State University College of Medicine professionalism program involves a step-wise approach as described below.
Alleged lapses in professionalism may be brought to the attention of any member of the Honor and Professionalism Council (HPC) or directly to the Associate Dean of Student Life. The Associate Dean investigates the concern in order to further characterize the behavior that has occurred. The Associate Dean speaks directly with the reporter (faculty member, resident, or fellow student) and has an exploratory meeting with the accused student to hear his or her viewpoint. Once the Associate Dean determines that the situation merits further evaluation, the case is referred to the Honor and Professionalism Council.
The HPC is comprised of students elected by their class peers, plus a faculty advisor. The HPC holds quarterly business meetings and ad hoc hearings. When a student is referred for a professionalism lapse, the HPC assembles a Hearing Committee. The Hearing Committee is comprised of student peers, the faculty advisor, and two non-voting faculty members who contribute input during the hearing. The student meets with the committee and is permitted to bring one individual (advocate) to speak on his or her behalf. During the hearing, the accused student has an opportunity to present his perspective to his peers regarding the behavior that occurred, to provide the context of the situation, and speak to other relevant details. The members of the Hearing Committee seek input from the student to verify the concern, to understand the student’s viewpoint, and to learn of any contributing factors. The HPC student members vote to determine whether a lapse has occurred. If the vote affirms that a lapse of professionalism has occurred, the Hearing Committee has an open discussion to formulate a plan of action. The plan is voted on by all members of the Hearing Committee, with a two-thirds majority vote required to approve the recommended remediation plan and a higher majority vote required if the recommendation is for student dismissal. The Associate Dean meets with the student shortly after the hearing to convey the HPC findings and remediation plan.
If the Hearing Committee determines that a professionalism lapse has occurred and that remediation is appropriate, specific interventions and remediation are recommended that are germane to both the individual student and the specific lapse to help the student grow and succeed in his or her professional development. Examples of suggested interventions include assigning the student a faculty mentor or coach, asking the student to prepare a written reflection, asking the student to prepare peer education materials, or referring the student to a specific college or university resource. The Associate Dean of Student Life reviews the HPC remediation plan with the student and implements the plan.
Students who have had a professionalism lapse are followed for any recurrent lapses. It is rare that students return to the HPC for another lapse, either similar or dissimilar, during the remainder of their time in medical school.
Summary and next steps
Several themes emerge from the published literature regarding remediation of professionalism lapses. First, as a medical profession we must maintain self-accountability and adherence to professionalism standards, and we must own and address our shortcomings. Assessment of professional behavior and remediation of lapses should be profession-led and occur across the continuum of practice from the medical student to the trainee to the practicing physician. Efforts to assess and guide professional development need to begin at the earliest stages of medical training.
Remediation programs that address professionalism lapses frequently take a graduated approach, with the intervention matching the severity of the behavior or the recidivism of the offender. Some remediation programs are highly individualized, resource-intensive, and time consuming,18 which further underscores the need to establish the most effective and efficient practices.
Finally, we need evidence- and outcome-based best methods. Having strategies for remediation of professionalism implies that we are able to identify individuals who are not competent and that remediation is a successful strategy for correcting deficits in professional behavior. Heretofore, there has been a paucity of evidence to guide best practices of remediation in medical education at all levels.12 To remedy deficiencies in professionalism, physicians and physicians-to-be may need role models, explicit instruction, guided practice, and mentored reflection. Outcome measures that help define the effectiveness of various methods will lead to further refinement of remediation strategies and perhaps to better specificity of methods based on type of behaviors or learning level.
In summary, the medical profession and its individual members must hold itself accountable to standards of competence, ethical values, and interpersonal attributes.2,3 This call for accountability challenges us to better identify individuals who are not meeting standards of professionalism and to find the best ways to change their behavior.
- 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.
- 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.
- Leach DC. Transcendent professionalism: Keeping promises and living the questions. Acad Med 2014; 89: 699–701.
- Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med 2010; 85: 220–27.
- Bryden P, Ginsburg S, Kurab, B, Ahmed N. Professing professionalism: Are we our own worst enemy? Faculty members’ experiences of teaching and evaluating professionalism in medical education at one school. Acad Med 2010; 85: 1025–34.
- Roff S, Chandratilake M, Mcaleer S, Gibson J. Preliminary benchmarking of appropriate sanctions for lapses in undergraduate professionalism in the health professions. Med Teach 2011; 33: 234–38.
- Zbieranowski I, Takahashi SG, Verma S, Spadafora SM. Remediation of residents in difficulty: A retrospective 10-year review of the experience of a postgraduate board of examiners. Acad Med 2013; 88: 111–16.
- Teherani A, O’Sullivan PS, Lovett M, Hauer KE. Categorization of unprofessional behaviours identified during administration of and remediation after a comprehensive clinical performance examination using a validated professionalism framework. Med Teach 2009; 31: 1007–12.
- Lucey C, Souba W. Perspective: The problem with the problem of professionalism. Acad Med 2010; 85: 1018–24.
- Cohen JJ. Professionalism in medical education, an American perspective: From evidence to accountability. Med Educ 2006; 40: 607–17.
- Myers MF, Herb A. Ethical dilemmas in clerkship rotations. Acad Med 2013; 88: 1609–11.
- 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.
- Buchanan AO, Stallworth J, Christy C, et al. Professionalism in practice: Strategies for assessment, remediation, and promotion. Pediatrics 2012; 129: 407–9.
- van Mook WN, Gorter SL, De Grave WS, et al. Bad apples spoil the barrel: Addressing unprofessional behaviour. Med Teach 2010; 32: 891–98.
- 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.
- Brigham and Women’s Hospital. Center for Professionalism and Peer Support. http://www.brighamandwomens.org/medical_professionals/career/cpps/. Accessed May 25, 2014.
- Parran TV Jr., Pisman AR, Youngner SJ, Levine SB. Evolution of a remedial CME course in professionalism: Addressing learner needs, developing content, and evaluating outcomes. J Contin Educ Health Prof 2013; 33: 174–79.
- Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006–2012. Acad Med 2014; 89: 352–58.
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Updated on May 14, 2015.
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