Our article will address an important issue in medical education: the assessment of professionalism in medical students and residents and the remediation of individuals who behave unprofessionally. Although medical students and residents are often governed by very different work rules (i.e., medical students are in an educational environment and residents are hospital employees), we will discuss common themes and principles in managing professionalism and outline a model process. This outline is meant to start a dialogue of common principles in medical education and present a framework to develop structures to assess, follow, and remediate medical students and residents with professionalism problems or concerns.
Educators are charged with assessing knowledge, skills, and attitudes of trainees. The assessment of a trainee’s attitudes (a.k.a., professionalism) is an essential aspect of development as a physician. Most medical educators would agree that learning how to deliver care in a professional manner is as necessary as learning the core scientific data and that professionalism is no longer a peripherally acquired skill (1, 2).
Identifying problems early and addressing them in the educational environment are crucial in the career development of trainees. Consider that medical students with professional problems are at increased risk for subsequent disciplinary actions by state medical boards due to ongoing difficulties beyond the training years (3). Yet professionalism can be difficult to define. We all think we know unprofessional behavior when we see it, but developing objective criteria and educational goals can be difficult.
Educating trainees about professionalism may occur as one component of ethics training (4). The two topics are clearly interrelated; however, professionalism entails domains that are also distinct from medical ethics. For example, identifying and working within physical, emotional, and other relationship boundaries with patients is an essential part of professionalism that is usually not explored during ethics modules. Professionalism needs to be specifically taught, modeled, and monitored throughout the curriculum (1). Most medical schools have formal professionalism curricula in place, but teaching professionalism as a theoretical subject will likely have little influence upon the behavior of future physicians. Additional strategies such as explicit and consistent role modeling of professional behaviors, reflection, and self-assessment are needed to encourage the development of professional practitioners (5).
Our review will cover the development of standards of professionalism in medical education, teaching, and modeling professional behavior so that the standards are clear and measurable, and we will offer strategies for remediation of unprofessional conduct.
Historically, professionalism has been perceived as an attribute that would naturally be acquired during medical school and residency education (1). However, a variety of challenges arise during training that may threaten professionalism, including chronic fatigue and sleep deprivation; stress and overwork; lack of confidence, self-esteem, and experience; difficult patients; and chaotic, unstructured, and unsupervised rotations (6).
One often unaddressed barrier to a trainee’s understanding of professional behavior is unprofessional conduct by educators. Many attending physicians and educators exemplify the standard of placing the patient at the center of an ethical framework consisting of altruism, respect, honor, integrity, excellence, and accountability. Yet, medical students and residents may also witness unprofessional behavior for which medical educators are not held accountable. For example, supervisors may violate patient confidentiality, be disrespectful of other physicians, or disregard hospital policies. The trainees may witness arrogant faculty or abuse of power by their attendings. In addition, this unprofessional conduct may be protected by an established hierarchy of authority that trainees learn as part of the implicit or “hidden” curriculum of medical education (7–9). The educational environment may never be able to eliminate these barriers, but by their recognition, efforts may be successful in circumventing them and their potential damage (6).
Much of the literature on educational programs and the assessment of professionalism in medical education has been published over the last 15–20 years, corresponding with a changing image of the medical profession. Patient complaints, malpractice lawsuits, and media stories that depict the inequity and high costs in the U.S. health care system highlight the shortcomings in the practice of modern medicine and contribute to the growing distrust from the public (10). The picture of the idealistic family doctor who had a personal relationship with his or her patients has been eroded with the perception that many doctors are controlled by greed and conflicts of interest (10), and there is an increasing call for more scrutiny and regulation. The 2008 hearings by Senator Charles Grassley (Iowa) on the conflicts of interest between psychiatrists and pharmaceutical companies are but one example.
On the basis of public concern and a desire to address professionalism issues internally, medical education groups started several initiatives. In the 1990s, the American Association of Medical Colleges (AAMC) undertook the Medical School Objectives Project (10, 11). The project’s goal was to define knowledge, skills, attitudes, and values that medical students should demonstrate before graduating. Examples included altruism, respect, compassion, honesty, and integrity (12). Today, most medical schools involve students in activities intended to enhance knowledge and understanding of the expectations of physicians in professionalism, using guidelines created by the Medical School Objectives Project (12). The AAMC has also mandated that each student’s professional behavior during medical school be evaluated and discussed in the Dean’s Letter, which is sent to all residencies to which a graduating student applies (10).
During this same period, the American Board of Internal Medicine (ABIM) established Project Professionalism to enhance the evaluation of professionalism as a component of clinical competence and to promote the integrity of internal medicine physicians. The project also specified the most important attributes defining professionalism: altruism, accountability, excellence, duty, honor, integrity, and respect for others (6); these are summarized in Table 1. In 2002, after collaboration among the ABIM Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine, the three fundamental principles of professionalism were defined as primacy of patient welfare, respect for patient autonomy, and a commitment to social justice (13).
Residency training programs have also made a commitment to include professionalism among their goals. The Accreditation Council for Graduate Medical Education (ACGME) defines professionalism as a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. In 1997, the ACGME identified six core competencies that should be met to become certified in any residency specialty. The psychiatry program requirements, as outlined by ACGME, state that residents must “demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.” Residents are expected to demonstrate compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation; and high standards of ethical behavior which include respect for patient privacy and autonomy, maintaining appropriate professional boundaries, and understanding the nuances specific to psychiatric practice (14). Even though these criteria are a good starting point, assessing professionalism remains difficult when there is no “gold standard” of behavior with which others can be compared (15). It is the responsibility of the individual program to design a curriculum in which professionalism is taught and monitored and, if necessary, steps are taken to remediate trainees who do not meet the standards.
Once the educational goals for professionalism have been defined, there are many practical problems with assessing professionalism and addressing concerns in the educational environment of medical student and resident education. Trainees move from rotation to rotation often with little continuity from instructors. Lapses in professionalism are usually subtle and could easily be overlooked. In addition, there is not a consensus on how best to handle the more common mild-to-moderate professional lapses (1).
Trainees may also act differently in different settings, and problematic behavior may not occur in the setting of the attending physician who is responsible for the final assessment. For example, a trainee may act very differently when on rounds than in a nurse’s station late at night or in a room alone with a patient. As the locus of medical care becomes increasingly based in outpatient clinics, lack of longitudinal observations of trainees centralized in inpatient environments decreases the likelihood of identifying subtle but important professionalism learning opportunities. In fact, lapses in professionalism are more likely to be identified and addressed in inpatient settings than in outpatient ones (16).
Another challenge of assessing professionalism and providing feedback to trainees centers on attending physicians providing formative feedback about observed behaviors. First, physicians can disagree about what behaviors are appropriate and professional in unique situations (17). For example, one attending physician may counsel trainees to hold patients’ hands when they are grieving, while another attending may find that behavior to be unprofessional. This creates the possibility of providing mixed messages to impressionable trainees who can become confused over time. A formal, in-person discussion between attending physicians and trainees about the specificity of professionalism in particular clinical situations is the best way to avoid this potential confusion (16). The investment in time, effort, and follow through may be prohibitive for busy attending doctors who often receive little or no compensation for teaching.
Given the importance of role models in developing professional behavior, an implicit feature of teaching professionalism is faculty and staff development in maintaining an environment that fosters professionalism. The substance of professionalism must be incorporated in the day-to-day lives of practicing physicians and reflected in their observable behaviors if the trainees are going to develop these values (18). Consider the teaching of an abstract concept such as respect for patients. Branch (19) proposes that to model respect in bedside teaching, the educator must use formal teaching exercises involving patients and deep critical reflection using narratives to describe experiences in patient care. Other curriculum have been developed to teach humanistic behavior to faculty (20–22), and developing humanistic teachers is the first step in creating an environment for teaching professionalism.
Professionalism is clearly a learned behavior, and some have called the faculty actions observed by trainees “hidden curriculum” (13, 23). A resident addresses nurses using the same tone as his or her attending, and a medical student observes the resident and adopts the same stance. The attending’s approach to a difficult patient will markedly influence how trainees on the service address the patient and the nursing staff. Yet most teaching services have no mechanism for giving the attending formal feedback in professionalism, and few hospitals have developed formalized mechanisms whereby the staff can give anonymous feedback on concerns related to physician conduct. The feedback forms for patients are often routed through hospital administration and bypass teaching portfolios and promotion committees in the university, missing a valuable chance to directly address concerns with physicians.
Attending physicians (and hospital staff) should be assessed on professionalism, and trainees should have the opportunity to address concerns. In fact, the opportunity to give appropriate feedback and address these concerns is an important skill to learn in developing professional behavior. Teachers should receive formative feedback on professionalism, and this feedback should be incorporated into their teaching evaluations, part of their annual and promotion evaluations.
Many hospitals and clinics now have formalized mechanisms for collecting patient feedback on doctors using randomized surveys that are collected by a third-party vendor and given to the administrative staff to review. Although these data are available for hospital credentialing, they are often not available to the persons in the department responsible for medical student and residency education. Consider that in most medical education systems, a doctor with lapses in professionalism (e.g., consistently not answering pages, receiving multiple complaints from families and patients, acting condescendingly to nursing staff) might not be identified by the education staff assigning teaching cases.
For professionalism to be taught effectively, there should be a culture of professionalism, and trainees should be part of that culture. Patient and staff feedback should also be routinely requested for all members of the team, and lapses of professionalism should be openly discussed among team members. Given the structure of medical hospital and clinic teams, trainees and staff are often at a disadvantage and need an anonymous mechanism to lodge complaints. This mechanism needs to feed directly into an evaluative process and teaching portfolio for the attending. Departments and medical schools also must highly value teaching and seriously consider evaluations and efforts in education when completing performance reviews or determining promotions.
A formal mentoring system can be a very effective mechanism in developing role models and teaching professionalism (24). In medical schools this has been done with the society system or in small groups with selected faculty who follow students throughout their medical careers. The same has been done with schools that have formal requirements for faculty mentors and have classes and seminars to develop these mentors. Encouraging longitudinal mentors to follow students’ evaluations and collate feedback from multiple attendings from multiple sites may be the best way to develop a comprehensive, realistic picture of trainees’ professionalism over time. Mentors who are aware of this information and do not have an evaluative but a formative feedback role in trainees’ education can provide the most effective and constructive feedback on professionalism.
Perhaps the most important factor in assessing professionalism in an educational setting is to develop clear and measurable standards for professionalism for the attendings, staff, and trainees. These standards should be measurable, and formative evaluations with feedback on a regular basis are powerful and essential tools designed to inform the individual of areas of strength and concern. Trainees are particularly vulnerable to the vagaries of a seemingly abstract comment such as “professionalism.” Professionalism needs to be broken down into objectively measurable behaviors, and the minimal criteria to meet these standards should be stated.
Difficulties in assessing professionalism may include the frequent use of abstract, idealized definitions, the context-specific nature of professionalism, and the reluctance of evaluators to address minor lapses in professionalism (17). Many attributes cannot be tested on a written or oral examination. Therefore, patterns of behavior, as observed within the educational environment, play an important role (6).
There is not a consensus on how to best identify unprofessional behaviors. Methods have ranged from a question regarding interpersonal skills on the overall clinical evaluation form to developing a specific form for unprofessional behavior that is completed on individual students or residents with deficits in this area (1, 25). Each assessment method has strengths and weaknesses (26), and the validity, reliability, and practicality of many of these methods have been called into question in recent reviews of the literature (27). Swick and colleagues (28) examined the assessment tools currently available, including global evaluations, self-evaluations, checklists, 360-degree evaluations, standardized evaluations, and direct observations. The strengths and weaknesses of various assessment tools are reviewed in Table 2.
Stern (29) suggested various criteria to obtain a complete and accurate picture of professionalism. He proposed that effective professionalism assessments should use multiple methods by numerous assessors over time. In addition, the evaluations should be based on observations within realistic contexts, involve conflict or situations likely to challenge professionalism, not be overly stringent (because trainees cannot be expected always to behave perfectly), be transparent to students, and ensure that everyone is evaluated similarly (5). We agree with that approach and will recommend some basic principles.
First, professionalism should be part of the objectives for every course, rotation, and evaluation of trainees throughout their education. As noted earlier, professionalism should also be evaluated not only in trainees, but also in their teachers, and should be part of the culture of the learning experience. Both supervisor and peer assessments and feedback may be useful, given the specific relationships trainees have with each group (15).
Second, the goals and objectives must be clearly defined using objective criteria that can reliably be measured by many different evaluators at different levels of training and at different sites. Many professionalism measures go across learning sites and levels of training, including reliability and responsibility; self-improvement and adaptability; relationships with students, faculty, staff, and patients; and upholding professional principles. Faculty at each site are charged with developing objectives and goals and descriptions of professionalism that can be reliably assessed at their site. A first-year medical student in an anatomy lab working with other students to dissect a cadaver can be reliably assessed on the ability to accept criticism and work with a team as easily as a fourth-year chief resident who is in charge of a psychiatric emergency room. The goals and objectives and the measurement criteria may change, but the same principles will apply.
The ABIM Project Professionalism identified unacceptable behaviors for meeting the standards of physician professionalism, including unmet professional responsibility, lack of effort toward self-improvement and adaptability, diminished relationships with patients and families, and diminished relationships with health care professionals. Unmet professional responsibility includes needing continual reminders about fulfilling responsibilities to patients and other health care professionals, unreliability in completing tasks, and misrepresenting or falsifying actions and/or information. Lack of effort toward self-improvement and adaptability includes resistance or defensiveness in accepting criticism, unawareness of personal inadequacies, resistance to considering or making changes, not accepting responsibility for errors or failure, being overly critical or verbally abusive during times of stress, and demonstrating arrogance. Diminished relationships with patients and families may be demonstrated by a lack of empathy or insensitivity to patients’ needs, feelings, and wishes or to those of families; lack of rapport with patients and families; or a display of inadequate commitment to honoring patients’ wishes. Diminished relationships with health care professionals may be demonstrated by an inability to function within a health care team or lack of sensitivity to the needs, feelings, and wishes of the health care team (6).
Starting professionalism evaluations early in training and continuing these evaluations are important to provide students or residents with opportunities to change (26). A challenge with medicals students is that the assessment of professionalism is often delayed until clerkship rotations. However, it is desirable and possible to begin assessing student professionalism during the first year of medical school (26, 30). The same can be said for residents who often move from more intensive inpatient environments to outpatient environments, where the challenges change but the culture of maintaining an environment of professionalism should remain.
Third, trainees should be assessed by multiple evaluators. This is typically done using a 360-degree evaluation, which includes input from patients, staff, attendings, and fellow residents and can also be conducive to creating a culture of professionalism. For example, the secretary in the medical education office and the ward secretary can have valuable insights into how a trainee manages stressful situations and interacts with staff. Including all the people who have contact with the trainee in the evaluation, outlining the goals and measurable outcomes for professional behavior, encouraging the attendings, staff, colleagues, and even patients to participate in the development of the trainees, and making clear the professionalism goals add to the culture of professionalism.
Fourth, although trainees move to different rotations and across different sites during their medical student and resident years, it is crucial to ensure a longitudinal evaluation of their progress in maintaining the goals of professionalism. Clearly the lack of longitudinal follow up is a major weakness in evaluating professionalism in many programs. Trainees often have only transient interactions with a large number of faculty and resident evaluators, and there is often a lack of communication among faculty across clerkships and courses regarding students’ performances (1, 25).
One potential solution to following trainees across rotations and sites is establishing a Progress and Promotions Committee (PPC). The PPC takes on many forms, but at its core, it is a group of faculty charged with evaluating and following students throughout medical school and residency. Trainees who have had professionalism issues are discussed in the PPC, and the PPC can guide remediation of students that have been identified as having professionalism concerns. The PPC also can help the institution define professionalism and reinforce a culture that supports using professionalism as a key criterion for promotion.
The makeup of the PPC and the “trigger” for referring trainees varies by institution. The chair of the committee should ideally be someone who has minimal direct interaction with the trainees if possible, so that he or she can provide a dispassionate view of the facts before the committee and ensure an orderly process for assessment and remediation. However, in smaller residency programs, it may be difficult to have a chair with minimal trainee contact, and often the residency director will serve in this capacity.
The membership of the committee varies widely, and some schools prefer that the members are course directors so that they can track students. At other institutions the PPC includes educators who are removed from regular trainee contact. Both have advantages: familiarity can be useful in contextualizing students’ behaviors, while objective views may also prove helpful when unprofessionalism is identified in well-known and well-liked trainees.
The PPCs are primarily aimed at supporting trainees. Those judged to be in need of assistance are invited to attend the PPC. The trainee’s professionalism concerns are discussed and a response is negotiated within the group. Most cases are resolved with clarification and discussion. Monitoring and follow-up interviews are arranged as necessary. The essence of this stage is support. In instances of attitudinal and behavioral inadequacy, the same advisory, supportive, and insight-giving strategies are employed. If independent “needs assistance” notifications are establishing a pattern of inappropriate behavior, the student is informed of the potential assessment implications. The PPC is advisory to the medical school dean or residency chair and makes recommendations for promotion and remediation.
Given the important role of the PPC in medical school education, we propose that a representative from psychiatry be included in its membership. Frequently, “red flags” of substance abuse, mental illness, or adjustment problems related to trainees’ personal lives may initially manifest as unprofessional behavior. For example, a trainee who is brought up at a PPC meeting for consistently missing responsibilities on Monday mornings and/or Friday afternoons might be thought to be merely irresponsible and untrustworthy. Psychiatrists on the PPC may see this behavior pattern differently; namely, as a sign that the trainee may have a substance abuse problem. The remediation recommendations would be distinctly different based on the theorized cause of such unprofessional behavior. Psychiatric involvement in this assessment may help students with problems receive expeditious, effective treatment rather than punishment.
Another mechanism by which longitudinal data can be synthesized and feedback on trainees’ professionalism provided is a formal mentoring system, as discussed earlier. Trainees who are paired with mentors at the start of their education may develop close professional relationships with these mentors who do not formally grade or assess them. Mentors might tabulate and follow evaluations of their mentees through computer assessment systems, compiling information from multiple evaluators into a cohesive, general picture. Mentors may discuss these generalities with their mentees periodically without trainees’ fear of being judged or graded unfavorably.
Although professionalism has historically been difficult to define and monitor, and prioritized lower than core medical concepts in educational curricula, recent attention to formally training professionalism is gaining momentum. Core competencies for professional behavior that are specific, measurable, attainable, relevant to the practice of medicine, and time limited have been developed and must be highly prioritized in training physicians at all levels. Changing structures of the delivery of medical care, which have decentralized staff, resulted in more outpatient service, and limited teaching time of clinical attendings, make assessment of professionalism and remediation of unprofessional behavior more difficult. Notwithstanding, societal and collegial demand for professionalism in medicine is stronger than ever.
We have proposed several specific mechanisms to better ensure that medical trainees at all levels learn professional behaviors and are held to high standards throughout basic science and clinical years as well as during postgraduate medical education. Progress and Promotions Committees (PPCs) and mentors are ways in which longitudinal oversight of professionalism may be maintained.
For these models to be effective, other variables that initially appear to be indirectly related to training professionalism must also be bolstered. First, senior faculty and other staff must also be held to high professional standards, because modeling behaviors is a powerful teaching tool for trainees. Second, a low threshold for completing a professionalism report must be expected and promoted across all training sites. Having protected teaching time and time for face-to-face feedback is essential for making this strategy successful. Next, PPCs need to make certain that recommendations for remediation of unprofessional behaviors match the origin of the behaviors. Trainees with illnesses or personal problems must be referred to treatment, not disciplined; popular trainees must be held to consistent standards that are the same as for their colleagues. Finally, trainees deserve formative as well as evaluative feedback about their professionalism so that they will be able to absorb feedback without constant fear of grading retribution.
Training future physicians is a daunting task and a privilege. Medical knowledge does not automatically translate into good and helpful ways of behaving. Teaching professionalism through formal and highly prioritized curricula is paramount in helping develop new generations of compassionate and responsible physicians.