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Chapter 9. Remediating Professional Lapses of Medical Students:
Each School an Island?
Richard M. Frankel, PhD
Remediation: (Latin) Mederi = to heal + re = again.
Definition: to put right or reform1
I recently attended the Association of American Medical Colleges (AAMC) 2014 Midwest Regional Group on Educational Affairs Meeting in Cleveland, Ohio, where my colleagues and I conducted a workshop on remediating professionalism lapses among medical students. At the beginning of my portion of the workshop, which was devoted to describing the professionalism remediation program at Indiana University School of Medicine, I asked the audience of sixty or so participants, ”How many of you approach your remediation meetings with students with optimism, energy, and enthusiasm?” Not a single hand was raised. I then asked, ”How many of you have received any formal training in how to conduct remediation meetings with students or are aware of any national guidelines or best practices in this area?” Again, no hands were raised. Finally, I asked, “How many of you have on your bucket list of things you want to accomplish in your medical education careers remediating medical student professionalism lapses? Amidst smiles and laughter, no one responded by raising a hand.
After having served as the professionalism competency director at a large medical school for nine years, and as a medical educator with three decades of experience, I was not surprised by these responses. In fact, they confirmed or reconfirmed elements of my own experience, namely, that remediation of professional lapses among medical students can be challenging; that each faculty member responsible for professionalism remediation works in isolation, and that there are few specific resources available for how to effectively conduct remediation encounters with students. The one area that felt at odds with my own experience was the bucket list question. Although it was not on my list initially, I have found my remediation encounters with students to be immensely rewarding and meaningful.
My goals in this chapter are threefold: first, I describe the professionalism competency program at Indiana University School of Medicine and the steps involved in the remediation process; next, I present three cases to illustrate my approach to the remediation encounter and its similarities to interviewing difficult patients; finally, I offer analysis, commentary, and suggestions for some steps that might be taken to stimulate national dialog around remediation processes and outcomes.
In the beginning . . .
In October of 2004, I became the third professionalism Competency Director (CD) at Indiana University School of Medicine, a position that was created in 1999 when the school adopted what was then only the second comprehensive undergraduate medical school competency curriculum in the United States. The curriculum was adopted after seven years of self-study and covered nine core competencies, including:
- Effective communication
- Basic clinical skills
- Using science to guide diagnosis, management therapeutics, and prevention
- Life-long learning
- Self-awareness, self-care, and personal growth
- The social and community contexts of health care
- Moral reasoning and ethical judgment
- Problem solving
- Professionalism and role recognition.
The overall competency curriculum has been fully implemented since 1999. Each competency has a statewide director, a portion of whose salary is paid by the Dean’s Office.
Professionalism in a Box
In my first week as CD, a box (see Figure 1) with articles, books, pamphlets, and videotapes was delivered to my office from the previous director, who had retired and moved to another state. The accompanying note congratulated me, wished me well, and said that the box contained all the material on professionalism that he had collected during his tenure. I was, of course, happy to get the material and immediately began digging into its contents. Many of the papers defining professionalism were familiar to me from work and teaching I had already done in the area. So, too, were the debates about whether professionalism consists of a set of timeless precepts and values or whether it is more like a complex adaptive system, a complex contextual cultural construct that changes as societal attitudes and values change.2–7 As important and complex as this debate was, what struck me as interesting, and somewhat concerning considering the fact that I was going to have to do real-time remediation meetings with medical students, was the scarcity of material on how to actually conduct such meetings. As I reviewed the published literature I became alarmed about the paucity of research and outcome studies that have looked at best practices for remediating clinical skills in general,8 and professionalism lapses of undergraduate medical students, in particular.9,10 What there was tended to be based on small samples from individual schools with little practical guidance on what to look for, how to act, and how to assess success or failure of remediation efforts, especially given the gravity of decisions being made about students’ career aspirations in medicine.
For example, Buchanan et al. suggest the following steps be taken in the remediation encounter: (1) confirm the lapse, (2) understand the context, (3) communicate and discuss in a mutually respectful manner, (4) encourage self-reflection, (5) agree on a plan for remediation, (6) document the interventions, and (7) construct a plan for follow-up.11 While checklists of this sort are undoubtedly helpful, they are insensitive to the face-to-face interactional contexts in which remediation meetings take place. I needed practical strategies for how to approach my meetings with students, and guidance on what to say and do, not a checklist of topics to cover.
Mechanics of the professionalism competency at IUSM
In addition to an academic transcript, each student at IUSM carries a competency transcript that appears on a combined grade sheet. Failure to satisfactorily pass the competency curriculum means that a student is not qualified to graduate from the medical school. Students must demonstrate competency at three different levels.
To qualify for Level 1 status, students must be able to:
- Describe to others the core behavioral abilities of the IUSM competency in professionalism—excellence in humanism, accountability, and altruism.
- Understand the acquisition of professional abilities as phronesis (practical wisdom).
- Identify professional behaviors ranging from expected (normative) to exemplary, to unprofessional in both the formal and informal curriculum.
By the time of graduation all students must have achieved Level 2 status and have:
- Mastered core professionalism skills in teams.
- Be able to articulate expected professional behaviors under stressful or challenging circumstances.
- Demonstrate the core abilities of professionalism in all IUSM-related interactions with colleagues, faculty, staff, administrators, patients, the health care team, and others.
Level 3 requires students to select three of the nine competencies to learn about in greater depth than the standard curriculum. To obtain Level 3 in Professionalism, students select a topic that will affect their learning in future stages of their careers, for example, in residency or practice. Working with a faculty mentor, students seeking Level 3 do research or observe in one or more actual settings, keeping a log of what they encounter. The log is then used as data for analyzing formal and informal elements of professionalism in the chosen setting(s). Students submit a final report describing their findings and what they have learned about professionalism that will affect them as they progress in their career.
Managing the professionalism competency: The Director’s role
The CD’s role consists of three main functions:
- Developing and maintaining the professionalism curriculum for medical students across all four years of training.
- Acting as a resource for students and faculty with concerns about their own or others’ professional behavior.
- Serving as the “remediation arm” of the Student Promotions Committee (SPC) where cases of unprofessional behavior are adjudicated.
In this chapter I will deal primarily with the third function of remediating professionalism concerns and lapses.
Figure 2 illustrates the competency management pathway. A course director, clerkship director, or faculty member from any of the nine school of medicine campuses begins the process by entering a competency concern or an isolated deficiency (ID) in the statewide electronic evaluation system. Competency concerns generally fall into the category of minor professionalism issues such as appropriate dress for class or clinic, or major lapses such as cheating or failure to show up for clinic or abandoning other clinical responsibilities. Although there is some variability in how the criteria for assigning a concern or deficiency are interpreted across the school’s nine campuses, course or clerkship directors often engage the CD prior to submitting their assessment. Concerns are handled informally between the faculty member, the student, and the CD, whereas IDs involve a formal process that requires a “progress hearing” with SPC to determine whether the student will be able to remain in school or will be dismissed.
At the same time the concern or ID is registered, the student is notified of the action being taken. In the case of a concern, the CD is also alerted and information about the source of the concern is shared with him. The student is required to meet with the CD to discuss the concern and plan appropriate steps to deal with it. The CD then relays notes from the meeting to the course or clerkship director and there is ongoing informal communication about the student’s progress in dealing with the concern. Importantly, competency concerns do not appear on the student’s permanent record and thus do not play a role in the Dean’s letter or any other formal record of the student’s performance during medical school.
An ID automatically triggers a progress hearing before SPC. The committee consists of twenty-four faculty representing basic and clinical sciences from the nine campuses. Students called for a progress hearing are required to address the issues raised concerning their professionalism and present their explanation for the lapse(s) to the entire committee. In addition, the student is expected to propose a plan to address how he or she intends to deal with the deficiencies. A question period follows the student’s presentation, after which the student is excused and the SPC votes on whether to dismiss the student or put him or her on probation with a required remediation.
In cases where SPC votes to dismiss a student, two options are available: the student may request another opportunity to present his or her case to the committee for a vote; if the second vote fails, he or she can make a final appeal to the Dean, who can choose to uphold or overturn SPCs decision.
As an alternative to dismissal, the committee can decide to place a student on academic probation and require successful remediation with the CD, who also sits on SPC. In this case, the student has an initial meeting with the CD, who evaluates the seriousness of the lapse, makes an educational assessment/diagnosis of the situation, and negotiates an agreed-upon remediation plan. Multiple face-to-face meetings may take place until the remediation is successfully completed. At that point, the CD reports back to SPC, which votes to accept or reject the recommendation to remove the student from academic probation and allow him or her to continue his or her studies, or to dismiss the student from medical school.
In the nine years that I was the professionalism CD, 105 students came before SPC for progress hearings. The majority of cases involved a single instance of a professionalism lapse that varied from falsifying documentation in a procedure log to signing others into lectures and other required activities. A smaller number of cases involved students who engaged in dishonest behavior, such as leaving the hospital cafeteria without paying for a meal. Similarly, there were a small number of more serious cases of dishonesty that involved cheating on exams or falsifying medical records. Finally, there was a handful of cases that involved accusations of cyber-bullying and stalking. Of the students who came before SPC, six were deemed unremediable with a recommendation to dismiss from the medical school. Cheating was the most frequent lapse for which dismissal was recommended. The rest were successfully remediated in a process lasting from a month to one year.
Case study 1: Responding to a competency concern12
I received a phone call from a basic science course director at a regional campus asking whether I would meet with a second-year student who, in the course director’s opinion, “was at risk for problems with professionalism.” He described the student’s behavior in the class he was teaching as inappropriate and childish, but not yet reaching the level of issuing an ID. Prior to, and sometimes during, class the course director reported that the student would say things like, “This is the stupidest course I’ve ever taken,” or, “The course instructor doesn’t know what he’s talking about half the time.” While these comments weren’t particularly hurtful personally, the director was concerned that the student’s disruptive behavior was a risk factor that could potentially lead to his being sanctioned or even a losing privileges or his license to practice at some future point in his career. Since his own attempts to reach out to the student had been unsuccessful, he wondered if having the student meet with me would produce a different result. I readily agreed to meet with the student to discuss the concern.
Todd came into my office full of bravado and bluster. I first asked him if he knew why he was in my office. He explained that he had a conflict with the course director and that this meeting was his “punishment.” He went on to say that the course director had it in for him because he had been born outside the United States and had been raised in New York City where things weren’t quite so provincial. He then asserted that he really didn’t care much about what others thought of him, especially the course director, as long as he got his work done and didn’t fail any courses.
I listened carefully to Todd, internally testing my own experience of having grown up in New York City and now having lived in Indiana for twelve years, with what I was hearing. At the same time I was internally reviewing what type of remediation exercise might be effective for raising awareness about the importance of professional conduct for a student who was well-defended and might have impulse control challenges. Rather than give him a lecture on professionalism, which I thought would be unlikely to have any effect, I suggested that he read Maxine Papadakis’ paper from the New England Journal13 on the link between practicing physicians who come before state medical boards for unprofessional behavior and unprofessional behavior while in medical school, and that we talk again in the next two to three weeks. He reluctantly agreed.
Less than twenty-four hours after our encounter, I got an e-mail from Todd wondering if we could meet “sooner than two to three weeks.” I happened to have an open hour in my schedule that day and replied, asking that he come in later that afternoon. Todd came into my office a different person. He looked exhausted and his eyes were red. I told him that I was surprised but glad to see him, to which he responded that he had read the Papadakis article the night before and had been “shocked” to discover that the article “described me to a ‘T.’ ” Tears formed, and he shared his fear that there was real danger ahead for him if he continued on the path he was on. After a long pause, he wondered out loud what he could do to keep his dream of becoming a physician and serving society alive in the face of his self-defeating behaviors.
We talked about various options that might be available, including psychological counseling. Todd was eager to pursue this course of action and confessed that he had thought of it a year earlier but rejected the idea as “weak minded.” After some discussion about what he thought would be helpful, we settled on a referral to a cognitive-behavioral therapist who works extensively with medical professionals. I had an opportunity to observe Todd in his third year in a small group narrative discussion that is held with students on their medicine rotation. At that point he seemed to have made a much better adjustment to his environment, those in authority, and his peers. The last contact I had with him was at graduation in 2011.
Analysis and comment
Three aspects of this case are worth commenting on: the opening gambit, the choice of remediation, and the result. In the literature on clinical interviewing, eliciting the patient’s perspective before sharing one’s own allows a clinician to adjust her or his response to the state of knowledge and point of view of the other rather than making inferences about what the patient does or does not know and understand.14,15 In this case, eliciting the student’s perspective at the beginning of the encounter allowed me to gather firsthand information about his perception about why the meeting was being held (as punishment). This opening gambit also allowed me to compare the student’s point of view and contrast it with what I had heard from the course director (concern for the student’s well-being).
The fact that the student felt as though he was being punished (persecuted) for his beliefs also provided important information about his point of view and likely responses to “suggestions,” rather than a formal remediation program, i.e., the difference between a concern and an ID. Running through the various options that I had for dealing with a defensive student (similar to working with a “difficult” patient) I chose to simply present him with the best available data on what is known about professional behavior of medical students and their subsequent risk of coming before a state medical board for unprofessional behavior and let him draw his own conclusions. The motivational interviewing literature was helpful to me here in pointing out that rolling with resistance rather than confronting it is more likely to result in a change in behavior.16 Evidence of the success of the choice of remediation approach and interviewing style is shown in the rapidity of the student’s response, his openness to seeking help to change, and his successful graduation from medical school without further incident.
Case 2: A clear-cut case of cheating
Several years ago, the clerkship director for OB/GYN sent me a “heads up” about one of her students, Albert, who had been struggling during the last part of the rotation, for no obvious reason, and was observed to have cheated on the shelf exam. SPC had been notified that the student would be receiving an ID in professionalism and would be required to make an appearance before the committee. Parenthetically, cheating is known as a “capital offense” among many members of the SPC. It is a core precept of the school’s honor code, and students who do cheat on exams have a high likelihood of being dismissed if cheating is confirmed. The clerkship director asked me to meet with the student to help him prepare for his SPC appearance. Before the meeting, I accessed his academic and competency transcript, which was excellent, and contained several course honors and no concerns or isolated deficiencies. I also reached out to the competency director for moral and ethical reasoning, with whom I had shared several cases, and asked her to be present at the pre-SPC meeting and partner in the remediation process.
Albert knocked on my office door, came in, sat down, crossed his arms over his chest, and was silent. My colleague and I asked if he knew why he was meeting with us and in a very matter-of-fact voice he said, “I cheated on the OB/GYN shelf exam,” immediately averting his eyes and looking down, after which an uncomfortable silence ensued. We then shared with him that we had reviewed his excellent academic record and that in our experience when incidents like this occurred there was often something going on in the background that helped explain making poor choices like cheating. Was that the case here, we asked? Another uncomfortable silence ensued and then with great hesitation Albert told us about receiving the news of his fiancée’s murder six days before the exam, and his feelings of helplessness and depression at being thousands of miles away. Through heaving sobs, he went on to describe his shame at what he had done and the consequences he would likely face after meeting with SPC.
After expressing our empathy for his loss and telling him that we understood how difficult it must have been for him to cope and to try maintain his studies, we encouraged Albert to share his story at his upcoming SPC hearing. He replied that he did not think it was possible to tell his story to twenty-four strangers and that he would sooner leave medical school than have to share his pain over what had happened. We reminded him that before this meeting we had been strangers and that he had been able, albeit with difficulty, to share his story with us. We offered to do a little bit of coaching and role playing about how to structure the presentation and an assured him that one of us would be there for support. In the end he agreed to present his story to SPC. Below is a fragment of the presentation he read to the committee.
No matter how hard I tried, I couldn’t get rid of the feelings of anger, rage, hopelessness, and guilt along with a constant tightness and chronic pain in my stomach . . . Toward the end of my OB/GYN clerkship, I found myself avoiding my work, avoiding people, and spending hours at a time in the restroom crying. I questioned everything that I ever believed in, including god. For the six days following that dreadful morning, I had little desire to do anything. As I sat for my OB/GYN exam, all I could do was think about her. Before I knew it, my time was running out and I made the poor decision of cheating on my exam, an action that in the past I had never even considered and for which I am deeply saddened and sorry.
After his presentation there were a few clarifying questions from members of the SPC who then voted unanimously to allow Albert to return to school after remediating his isolated deficiency. The remediation process included a recommendation for supportive counseling, doing library research and a paper on the problem of cheating in medical school, grief and mourning, writing letters of apology, and completing a personal reflection about the importance of asking for help and what his experience had taught him about professionalism and personal responsibility. Within minutes of receiving the news that he was going to be able to return to school after successful remediation Albert sent us an e-mail, part of which appears below:
I had my meeting today and the SPC committee has voted to allow me to continue with school! I am extremely happy and feel as if a huge burden has been lifted off of my shoulders. I would just like to thank both of you from the bottom of my heart for everything that you have done for me. You made an extremely difficult situation a whole lot easier to handle. Your understanding and friendly nature was like a breath of fresh air and made me feel extremely comfortable. Once again, thank you for your help, and support. I am eagerly looking forward to this new beginning. Thank you once again!
After his successful remediation and return to school, I did not hear from, or about, Albert for almost a year. It was his academic advisor who called me to discuss his “future.” His advisor told me that Albert had expressed a strong desire to stay at IU for his residency but was convinced that it would not be possible given the cheating incident and the fact that it was on his transcript and in his Dean’s letter. Together with my partner from the remediation process, and his advisor, we decided to contact the program director and offer our support for Albert’s application. It turned out to be unnecessary as the program director had already decided to accept him based on his academic performance and a strong interview that included a detailed explanation of the incident, his remediation, and what he had learned about professionalism from the experience. Albert was accepted into the program where he performed with distinction. Below is a fragment of Albert’s letter to me on Match Day, just after he learned he had been accepted to IU.
Dear Dr. Frankel:
I hope all is well. As you probably know, “match day” was today and I was able to get my first choice . . . at IU! You have been kind and generous with your time, advice, suggestions and guidance and I wanted to make sure that I write and let you know the results of my match. Thank you so much for all of your help throughout. I could not have reached this point without your guidance.
Albert is now in practice in the area, and has firmly established himself as a valued member of the medical community.
Analysis and comment
Like the first scenario, this case illustrates the importance of applying sound interviewing techniques, including empathy and support, to elicit the “narrative thread” of the events for which the student had been cited. In patient care, the narrative thread allows the interviewer to understand how clinical facts fit into the larger context of the patient’s life world.17–19 There are clear parallels in clinical medicine, for example, when patient behavior is viewed in isolation (e.g., a patient who fails to take her medication as prescribed) rather than in the context of their life situation (mother of four children who has no way to pay for the medication prescribed). The ability of the interviewer to explore the context of behavior in addition to the behavior itself is an important tool in clinical medicine that can be applied to remediation scenarios.
In interviewing the medical student before his meeting with SPC there was no question about the facts; the student himself said straightforwardly, “I cheated on the OB/GYN exam.” However, his affect (flat) and nonverbal behavior (arms crossed over his chest, averted gaze, looking down and away, all signs of shame or embarrassment20) were clear signs that there was more to the narrative thread than his opening statement. It has been noted in the patient interviewing literature that clinician silence in the medical encounter, i.e., acting as a non-anxious presence, often builds trust and encourages the patient to continue speaking.21–23 In this case, as uncomfortable as the silence might have felt, it revealed a story that was both compelling and heartbreaking. Although she was unsure why, it also matched the clerkship director’s comment that the student had struggled in the rotation, about the same time that the student reported getting the news about his fiancée’s murder. Once the student’s “back story” emerged, my colleague and I both used empathy, active listening, and support—patient interviewing skills known to increase the likelihood of adherence to recommendations made in clinical care24,25—to help the student with the decision to tell his story to the SPC.
Evidence of the effectiveness of the pre-SPC meeting and remediation is demonstrated in having correctly read the student’s non-verbal cues, using active listening and silence to create space for him to fill in the background of what happened around the time of the OB/GYN exam, corroboration of the timeline of events by the clerkship director, and genuine curiosity about the apparent disconnect between the student’s previous performance and his behavior in the clerkship. In the broader ecology of his professional formation, the fact that the program director was willing to invest in a student who had suffered a serious professionalism lapse, his performance during residency, and subsequent success in practice also suggests that we made the right decisions in advocating for him.
Case 3: Double jeopardy and faculty responsibility
A third-year student on her medicine rotation received an ID in medicine for having cheated on the final exam. The clerkship director informed me that the student would be coming before SPC and asked whether I would meet with her to discuss the situation, which I agreed to do.
In response to my opening question about why she thought we were meeting, the student acknowledged that it was because she had cheated on the medicine exam. In providing background to her behavior she described herself as a perfectionist who always put pressure on herself to perform and said that she wanted to maintain her GPA and get honors in the rotation because she wanted to go into internal medicine. A few minutes into the meeting I asked her whether she had shared her situation with others; her parents, in particular. She replied tearfully that she had told her parents and her fiancé, and that these were two of the most difficult conversations she had ever had in her life. She went on to say that she was ashamed of her actions and really wanted to better understand her behavior. She explained that between the time of the incident and our meeting, she had sought psychological help and was seeing a psychiatrist twice a week, that she was getting spiritual counseling through her church, and had assembled an “accountability committee” with whom she met weekly. Finally, she said that she was gaining a lot of insight into the emotional triggers that made her anxious and feel inadequate under stress and was learning healthy ways of dealing with them.
All in all, it seemed as though the student’s lapse had triggered a cascade of reflection and action that was helping her understand and deal with stress and the risks of her anxiety overriding her desire/ability to act professionally. In terms of preparing for her progress hearing with SPC, we discussed the need for transparency and honesty in taking responsibility for what had happened and the steps she was already taking to address her problems.
There was a two-month gap between the time that I met with her and her appearance before SPC. At her progress hearing the student presented a compelling account of all the steps she was taking, what she had learned about her response to stress, and healthy new habits and patterns that she was learning both in therapy and from her accountability committee. Toward the end of the meeting she put down her written statement, faced the committee and shared that as a first-year student there had been an incident in which she was observed to have briefly continued to work on an exam after the proctor had announced, “pencils down.” She was asked to meet with the course director to talk about what had happened. The student said that she had apologized for her action and the course director told her that, ”it wasn’t a big deal,” he wasn’t going to report it, and that she should follow the proctor’s instructions in the future. The student cited her sincere desire to get to the root of her “problem” and said that she wanted to be sure to leave no stone unturned in her quest for “the truth, the whole, and nothing but the truth.”
When the student was excused from the hearing a long discussion ensued among the SPC committee members. Most agreed that she was taking all the right steps to better understand and deal with her triggers, and that she was thoughtful, sincere, and honest in her presentation. At the same time, several committee members argued that her admission of an earlier professionalism lapse, despite the fact that it was minor and was not officially documented or reported, constituted a “pattern” of behavior that was unacceptable for a medical student and recommended dismissal. By a narrow margin the committee voted for dismissal, which was upheld in the appeals process.
Analysis and comment
This case raises several important questions. First, in my meeting with the student, many of the recommended steps for an individual who acts unprofessionally were already being taken voluntarily (confronting the problem head-on, psychiatric and spiritual counseling, eagerness to explore and learn about the effect(s) of stress on behavior). In addition, the student had faced those she loved, her parents and fiancé, and had taken responsibility for her actions by informing them rather than hiding what she had done.
From the literature on patient interviewing a key question about high-risk behaviors that one might encounter in highly stigmatized areas such as marital infidelity, high-risk sex, and alcohol and drug use is to assess whether there is a pattern of behavior over time.26 In retrospect, I realize that I failed to ask the student about whether she had experienced anything similar to the episode that occurred during the medicine rotation. Exploring the student’s history in more depth might have revealed the previous incident and led to a conversation about the significance of the instructor’s downplaying the incident and failing to take any action. It is, of course, speculation to believe that early detection and remediation would have prevented the student from additional cheating episodes, but it does seem likely that it would have helped her connect the dots and perhaps recognize that this behavior contributed to her dismissal from medical school.
A recently conducted national survey of medical schools’ professionalism remediation approaches by Ziring and colleagues at Drexel College of Medicine found that the major reasons for failure to adequately address professionalism lapses were:
- Faculty reluctance to report
- Lack of faculty training
- Unclear policies
- Remediation ineffective
Factors cited for reluctance to report were: faculty discomfort in determining the seriousness of the problem, the increased workload reporting creates for them, concern about harming the student’s future, the perceived minor nature of the witnessed lapse, and fear of repercussions.27 These findings echo the theme of physicians protecting one another and refusing to fail students for unprofessional behavior.28,29 As this case illustrates, my failure to elicit information about the frequency of the behavior in the pre-SPC meeting coupled with the reluctance of a faculty member to report the first instance of the student’s questionable professional behavior essentially placed her in double jeopardy for telling the whole truth to the committee. Sadly, it wound up costing the student her opportunity to complete her medical training.
I began this chapter by noting that there has been exponential growth of interest in professionalism in the last two decades. This is a positive development as faculty, researchers, and administrators have sought to define and operationalize the concept. Consensus statements, such as the Charter on Medical Professionalism have seen simultaneous publication in multiple journals in the United States and elsewhere.30 Many schools now have formal professionalism curricula and deans who support the importance of professional formation, as well as faculty who are responsible for maintaining professional standards and remediating students who have professionalism lapses.31,32
As interest in professionalism has grown, there has been corresponding interest in better understanding how different schools approach remediation and identifying best practices that can be translated into regional or national guidelines. The literature suggests, and my own experience confirms that, at present, each school is an island unto itself and that there is very little discussion and sharing about what constitutes an effective program of remediation from school to school. The need to systematically study this problem using evidence-based approaches has been identified and is gaining momentum.10 One possible approach to identifying best practices in remediation would be to use the approach the Accreditation Council on Graduate Medical Education (ACGME) took in implementing its six-competency curriculum for all residents.33 When they were introduced in 1999, ACGME “recommended” that all residents become competent in the competencies. It also asserted that evaluation of competencies was at a formative stage and that they would look to innovative strategies programs were developing and/or using to identify best practices. Four years later, in 2002, after having gathered systematic data on the most effective ways of evaluating the recommended competencies, the ACGME made successful evidence of achievement a requirement for graduation; not simply a recommended framework that was optional. The same strategy could be used to identify best remediation practices and over time use them to develop national guidelines with a common core of standards for evaluating the effectiveness of remediation processes.
Other approaches to reducing the fragmentation of knowledge about remediation in various medical schools might include collecting and reporting national data on the range of approaches schools take to deal with professionalism lapses. As well, offering skills-based faculty development and promoting a national dialogue about guidelines, opportunities, and challenges might help reduce the isolation of faculty charged with remediation. Finally, asking broader, deeper questions about medical school admissions practices and tools for identifying students who may be at risk for professionalism lapses could make the process of remediation more proactive than reactive.
The second theme of this chapter focused on the remediation encounter itself and methods drawn from evidence in the literature on patient interviewing. Faced with a paucity of practical information on how to conduct remediation encounters with students, I found that evidence-based patient-centered communication skills such as eliciting the patient’s perspective, using empathy and support, reading non-verbal cues, and principles of motivational interviewing to be extremely helpful in establishing the narrative thread of events surrounding professional lapses. In addition, such techniques often provided the deeper understanding that could not be found or deduced from the student’s file or the clerkship or course director’s notes. I also found that comparing the story with the course or clerkship director’s account allowed me to “triangulate” data from multiple sources that was helpful in confirming or disconfirming the student’s account.34 Using an evidence-based patient interviewing approach also permitted me to use a quality improvement framework to pinpoint errors in my own approach that could, and did, have significant consequences for at least one student.
The third theme was how we, as faculty, approach the remediation process. As the opening anecdote suggests, many faculty who do remediation work see it as difficult, challenging, and unrewarding, viewing it in much the same way as clinicians find working with difficult patients. Wendy Levinson, in a classic paper entitled “Mining for Gold,” described how, after years of frustrating encounters, she found something to like about one of her most difficult patients when she explored the narrative thread of the patient’s context, and how that understanding led to a positive transformation in their relationship and a shift in loyalty and trust.35 The lesson here is that it is critically important to approach the remediation process with an open mind, to remember that all human beings have redeeming qualities, no matter how egregious their professional behavior may have been, and that context matters.6 Whether helping a student regain his or her footing after a minor professionalism lapse or dealing with the possibility of dismissal after a major lapse, the goal, just as it is in patient care, should always be to find ways to be of service.
In closing, I suggest that we would do well to recall that the root word for remediation is mederi, which in Latin means “to heal.” Together with the prefix re, which means “again,” we arrive at a definition of remediation that focuses on strategies and approaches in working with students who have had professionalism lapses to heal again. As was true in the early days of the quality assurance movement, when the strategy was to weed out the bad apples, punish poor performance, and shame and humiliate those who didn’t conform to quality standards, many now suggest that strategies focusing on intrinsic motivation, autonomy, and self-regulation are much more likely to succeed in producing high-quality results.36,37 So, too, in approaching remediation encounters. If we re-frame the idea of punishing students for unprofessional behavior and instead treat it as an opportunity to help them heal (whether that means a student is dismissed or allowed to continue his or her medical education) we may find ourselves being more effective and more energized by the task, the process and the outcomes.
Many thanks go to Bud Baldwin, Frederic Hafferty, Thomas Inui, J. Harry (Bud) Isaacson, Deborah Ziring, and Liz Gaufberg for their careful reading of the manuscript and thoughtful suggestions for how to improve it.
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- Ziring D. Personal communication; 2014.
- Wilkinson TJ, Tweed MJ, Egan TG, et al. Joining the dots: Conditional pass and programmatic assessment enhances recognition of problems with professionalism and factors hampering student progress. BMC Med Educ 2011; 11: 29.
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