On teaching Professionalism

Adham Karim, MD

Professionalism is a multi-faceted concept that carries different meanings to different people; it ranges from a physician’s bedside manner and acknowledging mistakes, to how one interacts with their peers and if they show up on time. Not only that, but this all-encompassing term is cited as a core competency by the American Association of Medical Colleges. It is also a part of the American Medical Association’s code of ethics and explicitly mentioned in the syllabi of most medical schools and training programs across the U.S. Despite the broad acceptance of professionalism as a key character component of a well-rounded clinician, there is a significant difficulty experienced in trying to teach this to trainees. This may seem a little long-winded, but this is a subject that really resonated with me, and with JAMA instituting a professionalism section a few years ago, there have been more and more pieces published on the topic; I’m happy to see that this is gaining more traction. Everybody will tell you that administrative burdens and needing to deal with insurance providers for prior auths and the like definitely contribute to burnout, but having unprofessional colleagues can be just as burdensome and unsafe for patients!

I recently came across an excellent piece in the New England Journal of Medicine titled “Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework” wherein Dr. Wasserman, Redinger, and Gibb attempted to tackle the difficult yet important concept of professionalism in medical training. The article made a strong case for treating lapses in professionalism as if they were medical errors of varying severity, and they included an infographic, as well as gave several examples to go with this framework. In my opinion, professionalism is one of those behaviors that is nearly impossible to teach in a classroom and is often developed through a mix of modeling behaviors from more senior physicians, as well as a little bit of one’s own personality/temperament mixed in.

There was an example cited by the authors that centers around a medical student who has begun a collaboration with a mentor on some database analysis. The mentor states this is an IRB-exempt study and urges the student to begin analysis immediately, but the student’s research office instructs her not to download the data until getting an official exemption was issued by the IRB. The mentor pressures the student into downloading it anyways, and the student gets reprimanded for this. Wasserman et al suggest this is a lapse in professionalism at the lowest level – “no-fault suboptimality” resulting from the student’s faulty understanding that the supervisor (mentor) is right. They focus on teaching the student “strategies for diplomatically addressing her mentor” and acknowledge it is a difficult situation. What they don’t do, however, is acknowledge the context of this lapse of professionalism; they make no mention of addressing the mentor’s behavior or holding them accountable.

By all means, I agree that the student’s incorrect logic needs to be addressed. But, by not addressing the lapse in the professionalism of the mentor, I think the authors missed an opportunity to strengthen the analogy of professionalism and medical errors. In the “Just Culture” movement, physicians were just as accountable as nurses, who were as accountable as medical students for speaking up against unsafe practices. In this scenario, I would argue that the mentor is more liable, and should be held even more accountable than the medical student. As the authors have already made clear, trainees are still developing their understanding of professionalism, but this mentor is arguably an individual who has completed their training and should have a stronger grasp of professionalism than a mere medical student.

I concede that their article was aimed moreso at addressing lapses in professionalism of trainees, but this circles back to my personal view of how professionalism is developed. As others have stated, ensuring an individual trainee’s “competence in the area of professionalism requires the concerted efforts of many.” However, what about non-trainees? You could assume that a hospital board or professional society will self-govern to ensure professional behaviors, but with a term that is so loosely defined, and with financial incentives on the line, how much would someone be able to move the needle? I think most of us can remember at least one time (or many), when a senior physician tore into a helpless colleague, or became frustrated and lost their temper. How often do you think these individuals get a time-out or get part of their wages withheld as a punishment?

This brings me to my point: if the system is flawed, how does putting additional pressure on trainees fix that? The “do as I say, not as I do” approach has never been tested in a randomized trial, but conventional teaching theory (and common sense) will tell you that this is not effective. I myself am a trainee still (you’re reading the Fellows In Training blog, duh), so I certainly do not have all the answers.

From my time spent in developing medical school curricula, and sitting on academic disciplinary committees, I’ve come away with a few insights that I think might help. When the issue is a systems issue – such as “well everyone in my class skips grand rounds, I thought it was ok” the individual who got caught usually got caught due to chance, and reprimanding them would be unfair. Wasserman et al mentioned that the system needs to be changed, but didn’t talk about how. I’m gonna piggyback on that, because systems changes are difficult, and can be nuanced depending on the problem.

I think that lapses in professionalism should be addressed, but a better approach would be one that relies on positive feedback rather than only mentioning professionalism when it is missing. For example, in my medical school, and most training programs, at the middle and end points of a rotation, mentors would take the medical students for some formative “feedback”. Sometimes they were going off a form issued by the medical school, other times they would go off what they felt should be emphasized. If throughout a trainee’s career, different levels of professional behavior are emphasized by instructors, this could go a long way.

One example of this would be that mentors are instructed to focus on the aspect of timeliness and respectfulness with first-year students, making sure to comment on these in each student’s feedback; but when they give feedback to third years, they emphasize other aspects of professionalism, such as truthfulness, admitting to mistakes, knowledge gaps, etc.

Many theories have been put forth as to why professionalism can be such a difficult concept to teach and practice, but I think a critical shortcoming we have to acknowledge is the disconnect between the two worlds that trainees must straddle: the world in which we teach professionalism, and the world in which they practice.

 

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