Tools to assess and develop professionalism in medical students are emerging in medical schools across the nation. Graduating medical students are expected to competently deliver care in a professional manner that reflects respect for their patients. Historically, professionalism has been perceived as an attribute that would be naturally acquired during the course of being taught the critical core of scientific knowledge and clinical problem solving skills. In the past decade, the medical profession has specified the most important attributes defining professionalism that include altruism, accountability, excellence, duty, honor, integrity, and respect for others (1). In July 1998, the Association of American Medical Colleges (AAMC) recommended that medical schools include professionalism in the core curriculum of medical education (2). The AAMC and the National Board of Medical Examiners (NBME) jointly developed recommendations for improving the instruction and assessment of professionalism in May 2002 (3). Then in 2004, the NBME initiated the Step 2 Clinical Skills component to the USMLE, to assess the communication and interpersonal skills of graduating medical students (4). There is now consensus among medical educators that learning how to deliver care in a professional manner is no longer a peripherally acquired skill but rather one that is as integral to medical education as learning the core scientific data (5).
Medical schools have not reached a consensus about how best to identify, document, and intervene when students display unprofessional behaviors. Tools utilized for identifying unprofessional behaviors 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 with deficits in this area (6). In contrast to the myriad of tools available when deficiencies are noted in students’ fund of knowledge or clinical problem solving skills, there are few guidelines for addressing unprofessional behaviors. Several explanations have been offered for the lack of guidelines, including the transient interactions students have with a large number of faculty and resident evaluators, the lack of communication among faculty across clerkships and courses regarding students’ performances, and the perceived subjective nature of evaluating professionalism (6). The goal of this preliminary, exploratory study is to describe various methods used by psychiatry clerkship directors nationally to identify and address unprofessional behavior in 3rd year medical students. We report our findings from the distribution of a 20-item questionnaire about the assessment and remediation of unprofessional behavior.
A 20-item questionnaire (Appendix 1) was developed by the authors to assess the process by which unprofessional behaviors are identified, monitored, and remediated and to determine what, if any, disciplinary actions are taken when unprofessional behaviors are uncovered. The content of the questionnaire was developed from input provided by faculty members at the authors’ institutions, including clerkship directors of other specialties, associate deans, and committee members who review students with academic and professionalism difficulties. The available literature on professionalism evaluations used at other institutions provided further content areas that were included in the questionnaire (7, 8). The questionnaire was sent via e-mail or the postal service to all psychiatry clerkship directors in the U.S. listed as members of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) (9). We focused on the psychiatry clerkship in this study, because of the emphasis on the doctor-patient relationship in psychiatric training. The Institutional Review Boards (IRB) at the University of Cincinnati, OH, and Wright State University approved this study.
Excel was used for both data entry and analysis. We examined the frequencies across all the variables to assess the extent to which psychiatric programs are addressing unprofessional behaviors of medical students
Questionnaires were sent to the 120 members of ADMSEP comprised of clerkship directors and directors of medical student education for departments of psychiatry within the U.S. A total of 57 (47.5%) responded after two mailings were sent.
Fifty-five (96%) of the clerkships evaluate professional attributes in their students. Most of them (N=45/55, 82%) include one or more questions regarding professionalism within their general clinical evaluation forms. The remaining clerkships (N=10/55, 18%) use a separate professionalism form that allows for a more detailed inquiry. Professionalism is rated by faculty in 90% (N=50/55) and by residents in 87% (N=48/55) of the cases. Approximately 44% (N=24/55) of the respondents evaluating professionalism request feedback from non-MD raters including hospital staff, student peers, patients, and self-evaluations (F1).
The goals of evaluating professionalism, as identified by the respondents, include providing informative feedback to students (N=46/51, 84%); identifying students’ problematic behaviors (N=48/51, 87%); obtaining more detailed individual data to give support to numerical scores within the body of the dean’s letter (N=35/51, 64%); and identifying exemplary behavior (N=28/51, 51%). Professional attributes that are rated by at least 50% of the 57 respondents include reliability/responsibility, respect for patients, working effectively with a multidisciplinary team, appropriate attire, maintaining interpersonal boundaries, accurate clinical documentation, honor/integrity, maintaining patient confidentiality, use of professional language, and acceptance of constructive criticism (F2).
Seventy percent (N=36/51) of the respondents said that unprofessional behaviors are identified in 1—3 students per year whereas 24% (N=12/51) say they identify these behaviors in <1 of their students per year and only 6% (N=3/51) identify unprofessional behaviors in 4—6 students each year. Respondents’ comments suggest that negative evaluations usually result from a pattern of unprofessional behaviors being noted by one or more raters of the students during the clerkship. There are eight categories of unprofessional behaviors regarded as warranting an automatic referral to an Ethics or Promotion Board by >60% of the 55 respondents. These behaviors include substance abuse, drug theft, violations of the College of Medicine (COM) criminal code, cheating on exams, sexual impropriety, threats of harm/defamation, falsification of records, and sexual harassment (F3).
Unprofessional behaviors of lesser severity are referred to Ethics or Promotion Boards by 56% (N=31/55) of the respondents when students do not correct the behaviors during the clerkship despite being notified to do so and by 69% (N=38/55) of respondents when the behaviors have recurred across several clerkships. These situations are identified through a variety of mechanisms including clerkship directors’ meetings, departmental faculty meetings, departmental medical student education meetings, as well as informal individual discussions among those involved in medical student education including preceptors, clerkship directors, and associate deans. Eighty-eight percent (N=42/51) of the respondents said that the faculty preceptor who first observes the unprofessional behavior is typically the first person to discuss the concern with the medical student.
A majority (N=44/51, 86%) of respondents are aware that negative professionalism evaluations have "sometimes" impeded students’ advancement toward graduation. The severity of the behavior is most often (N=44/55, 80%) cited as the reason students are dismissed from school for professionalism deficits.
There are many strategies utilized for remediation of unprofessional behaviors, including assigning a faculty mentor specifically for professionalism deficits (N=17/55, 31%), assigning a faculty mentor and repeating the clerkship (N=35/55, 64%), and requiring mental health treatment for a student (N=26/55, 47%). Respondents’ comments suggest that the severity and frequency of the behaviors are integral to deciding what component(s) to include in individual students’ remediation plans.
The majority (N=29/38, 76%) of respondents report that students with professionalism deficits are referred for mental health evaluations. Clinical updates are requested from the treating clinicians by 67% (N=26/39) of the programs with the students’ written consent specifying the extent of information to be provided. Treatment compliance (N=20/55, 36%) and updates on clinical progress (N=19/55, 35%) are the information most often requested by the monitoring bodies. The clinical diagnosis is only requested by 7% (N=4/55) of the programs. The respondents indicate that this is most often sought in individual cases in which there is concern that the student’s behaviors may seriously compromise patient care as may be the case with substance abuse or psychosis. A minority (N=12/37, 32%) of the clinicians treating students receives academic updates regarding the identified students’ functioning within the COM. Most clinicians do not request such information but rather rely on the student/patient to provide this data. For those students requiring a leave of absence, an evaluation to assess a student’s readiness to return to clinical duties is most often requested from the treating clinician (N=35/55, 64%) and less often by a separate nontreating clinician (N=19/55, 35%).
In this study, information was collected about how psychiatric educators identify, monitor, and respond to unprofessional behaviors in medical students. Although a few individual programs have published their procedures for identifying unprofessional behaviors in medical students, to our knowledge, this is the first cross-sectional study to assess the methods used by psychiatry clerkship directors for evaluating professionalism.
Although the majority of respondents include questions about professionalism in their student evaluations, it is typically a small component of the overall evaluation. There is substantial agreement that the attributes of professionalism such as responsibility and respect for patients and other staff are optimal and that serious problems, such as substance abuse and sexual impropriety, warrant consideration of dismissal from medical school. However, evaluators differ in their responses to relatively minor or infrequently witnessed behaviors and may dismiss them as anomalies due to situation-specific circumstances or student inexperience. Faculty may also vary in their threshold for identifying behaviors as unprofessional based on their own embodiment of professionalism attributes. Previous studies of professionalism in medical school suggest that students may model the unprofessional behaviors of their mentors or refrain from questioning their mentors because of concern about the impact on their evaluations (10).
Many of the respondents have limited formal avenues for reporting problematic student behavior. A few of the respondents stated that discussions about students’ performances were not allowed at their departmental or clerkship directors’ meetings because of concern about inciting bias against a student. However, these respondents also indicated that this represented a missed opportunity to positively intervene on a student’s behalf early in his or her medical career. Other respondents have the opportunity to sit on college committees that review professionalism and academic deficiencies, affording them access to data from other clerkships as well as final determinations made from the Dean’s office on these students.
Several limitations of this study should be considered. First, because more than half of the clerkships did not respond to the questionnaire, the results may not be generalizable to all psychiatry clerkships. Second, the questionnaire was not validated, and the results should be considered preliminary. Third, we did not obtain demographic data on the responders and nonresponders, which may have provided further insight into possible trends based on geographic locations or sizes of institutions. Fourth, we limited this initial study to psychiatry clerkships. Future studies should expand the sample surveyed to include other specialties for further comparison of similarities and differences in the areas investigated. Fifth, we did not look for possible differences among the different types of evaluators of students such as patients, self-evaluations, non-physician staff, residents, and faculty to see if they differ in their assessments of students’ professional demeanor. Finally, we did not assess whether clerkships that had more detailed professionalism evaluations had a greater likelihood of detecting unprofessional behaviors, and future studies should examine this possibility.
In conclusion, unprofessional behaviors among medical students vary in their severity and their amenability to change. The preliminary data provided from this study suggests that most psychiatry clerkships evaluate professionalism but do so to varying degrees. There is not a consensus on how best to handle the relatively more common mild-to-moderate professionalism lapses. Respondents welcome opportunities to communicate about concerns regarding students within and across specialties to coordinate earlier interventions for students. Evidence is emerging that students with professionalism deficits are at increased risk for subsequent disciplinary actions by their state medical boards due to ongoing difficulties with professionalism beyond their training years (11). Fortunately, professionalism is gaining increased recognition as an integral component of medical education that needs to be specifically taught, modeled, and monitored throughout the curriculum.