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Concerns about medicine’s status as a profession have been growing for the past 80 years. By the late 1990s, many experts felt that medicine had become self-serving and insular, had violated its social trust, and was in danger of losing its vaunted professional status. The slowness of medicine’s awakenings notwithstanding, the inaugural decade of the twenty-first century was marked by a flurry of actions deigned to define, assess, and institutionalize professionalism within the classrooms of medical education and hallways of clinical practice. By 2000, for example, virtually every medical school and residency program had implemented some type of formal professionalism curriculum.
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Medical professionalism faces a number of challenges. Perhaps the most important is the need to reconcile professionalism being taught in the “classroom” (which includes the professionalism embedded in the codes, charters, competencies, and curricula) with professionalism being observed by learners in the clinical settings modeled on a day-to-day basis by more senior clinicians and faculty. At root is a classic hidden curriculum problem of the gap between efforts to formalize professionalism instruction and the day-to-day or moment-to-moment lived experience of trainees. In some cases, the gap has been great enough to cause some trainees to “push back” against and disavow the formal professionalism curriculum. Successfully developing and implementing approaches to teaching professionalism that integrate elements of the formal and informal or hidden curriculum remain elusive.
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Competency-based medical education has further defined, benchmarked, and assessed professionalism. The Accreditation Council for Graduate Medical Education (ACGME) professionalism competency emphasizes the development of professional character, high standards of accountability, humanism in all dealings with others, and altruism—putting the interests of the patient before self-interest. There are now a large number of readily available formal professionalism curricula, assessment tools, and literature (see web links and Suggested Readings). Although the challenge of formal versus informal curricula remain, these resources identify important aspects of professionalism and point to areas for further curricular development.
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Professionalism requires attention to several domains of physician behavior, including truth-telling, confidentiality, disruptive behavior, assuming responsibility, respectful communication with patients and colleagues, giving and receiving feedback, bullying, sexual harassment, personal appearance and attire, and others. In this chapter, we focus on three major professionalism issues: inappropriate use of social media, plagiarism, and boundary violations. We first define each challenge, then illustrate each with one or more cases. We end the discussion of each challenge with commentary regarding educational and institutional implications in four areas: (1) formal/informal curriculum; (2) faculty development; (3) institutional response; and (4) remediation.
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The explosive growth in information technology, especially the adoption of social media, presents a new challenge to professionalism. Concerns about sharing confidential patient information on public social media web sites, posting of inappropriate personal information, using social media at inappropriate times such as on rounds or during lectures and other educational activities, and failure to maintain good professional boundaries by, for example, “friending” patients on social media sites are among the problematic behaviors that have been noted among recent cohorts of medical students and residents. “Millennials,” or Generation Y (those born between 1980 and 1994), which includes medical students, residents, and to some degree fellows and junior faculty are almost constantly engaged in using social media. It is estimated that in the United States alone there are over 120 million users of Facebook, and that number is growing rapidly. This method of communication has supplanted other forms of interaction, including the telephone and even e-mail, which is more commonly used by older faculty. In the area of social media, faculty are what Prensky has termed “digital immigrants,” whereas their younger charges who grew up with digital technology are “digital natives.” Capitalizing on the benefits and understanding the risks inherent in social media remains a challenge for undergraduate and graduate training programs.
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CASE ILLUSTRATION 1: “A CLICK IS ALL IT TAKES”
A Student Reports: I recently posted an offensive and tasteless “doctor joke” for my friends to see on Facebook. Another medical student who viewed it thought the posting was highly unprofessional and put the school in a potentially negative light so brought it to the attention of school administrators. As a result of my actions I was required to make an appearance before the student promotions committee and face the possibility of dismissal for behavior unbecoming a medical student.
As a result of this experience I have become acutely aware of the attractions and dangers of social networking and its potential to do harm. Since a case in which a student at Rutgers committed suicide after compromising information about him was circulated on social networking sites, I have come to realize that I have a responsibility to recognize that one click of the mouse is all it took to jeopardize my entire future as a physician. (MS II)
The essay above, written by a second-year medical student and president of his class was published in SCOPE, Indiana University School of Medicine’s weekly electronic newsletter that is distributed to the entire medical staff of some 2500 people on nine different campuses. It was written after the student had been cited for unprofessional behavior and only was permitted to stay in school contingent upon successful remediation with the school’s competency director. The essay was voluntary, the result of a conversation between the student and two faculty members about alerting other students to the risks of posting information on social networking sites. The student volunteered to give a presentation based on his case to the entering freshman class.
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Educational and Institutional Implications
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Formal/Informal Curriculum
Many students and residents are unaware of the risks of using social media. For example, a study of online posting by medical students and residents found that only 37.5% made their Facebook pages private.
Modeling professional behavior in the informal curriculum
Engaging students in respectful dialogue and discovery about how and why they use social media can be helpful in bringing about behavior and culture change.
Enlisting student leaders who may have had experiences with professionalism issues relating to Internet usage may also help students recognize that the issue is serious and affects their peers and colleagues.
Faculty Development
Institutional Response
The use of social media by medical trainees is growing.
Surveys by school administrators to determine the extent of social media use and its appropriateness/inappropriateness can help give the school a sense of the extent of social media practices among students, residents, and faculty, and help shape institutional policy.
Few schools have written policies that specifically deal with social networking, but schools with any written policies about unprofessional behavior are better able to handle violations than schools without written policies.
Developing written policies that take into account school size and the range of problem behaviors can be helpful in crafting institutional responses that are targeted and appropriate.
Collaborative engagement of students, residents, and junior faculty in policy development facilitates implementation of the policies in question.
Remediation
There are currently no national standards for remediation of unprofessional behavior involving social media among medical students and residents. It falls to individual deans, course and clerkship directors, and faculty to come up with remediation procedures that are fair and fit the questionable behavior.
Apart from dismissal from school, remediation is best accomplished in the spirit of improvement and increased awareness of the risks associated with social media use. Personal research by students who have violated social media standards into what is known about millennials and their status as “digital natives” along with journaling and reflection are often useful.
Recruitment of student leaders who have had professionalism lapses and who share messages about the risks of inappropriate use of social media can be an effective method of “spreading the word” about expectations and appropriate behaviors.
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Another challenge in educating for professionalism is plagiarism. This problem may, in part, derive from the “digital divide” between generations and their knowledge and understanding of the rules that govern electronic, print, and written media. For example, evidence of plagiarism was found in 5.2% of the personal statements of residency applicants to a single institution by comparing them with readily available Internet sources. Likewise, in their undergraduate coursework some medical students believe that citing Internet sources such as Wikipedia or other websites is unnecessary because of the “open source” nature of these sites. Equally concerning is the trend among some faculty and trainees to “cut and paste” medical records in clinical care. Residents may observe their attending physicians engaging in this practice or get the message that it is okay to “cut and paste” a patient’s history from day to day or from previous hospital admissions. Medical students, for whom there is typically no formal instruction in this area, learn to follow suit. The result is an “epidemic” of behavior that is a threat to both professionalism and quality of care.
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CASE ILLUSTRATION 2: PLAGIARISM
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The Oxford English Dictionary defines plagiarism as “the wrongful appropriation or purloining and publication as one’s own, of the ideas, or the expression of the ideas … of another.” The two samples above come from the personal statement of an application for residency at Harvard Medical School (Column A) and a popular web site with examples of application essays (Column B). With the exception of two phrases deleted by the applicant and highlighted in italics, they are identical. Applicants must certify in writing that their essays are accurate and original. In the case of a residency application, the response to plagiarism is straightforward and involves rejecting the application and the applicant. With increasingly sophisticated tools available to prospective applicants as well as to faculty and administrators, the challenges of educating about, and monitoring for, plagiarism have become more pressing.
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Educational and Institutional Implications
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Formal/Informal Curriculum
Faculty Development
Many faculty members who suspect plagiarism in written reports are hesitant to invest the time and energy to prevent or “prove” these occurrences. Several automated programs are available to check for plagiarism (e.g., www.duplichecker.com, www.scanmyessay.com, and www.turnitin.com for admissions essays). In addition, faculty may not readily make the connection between activities like cutting and pasting of notes in the electronic medical record and plagiarism.
Faculty development seminars on how to detect and respond to instances of plagiarism can be quite useful in addressing the problem.
Raising awareness of faculty about the risks (malpractice and otherwise) of cutting and pasting their own hospital notes and the fact that residents and students will do as they see their role models doing may help address this problem.
Institutional Response
Clearly stated institutional policies, procedures, and consequences regarding plagiarism in the preclinical and clinical years are essential for students and residents to understand the risks involved in copying one’s own or another person’s words and ideas or falsifying records.
Academic policies as well as student promotions committees can be helpful in setting standards. Working together with student leaders to develop standards can facilitate their acceptance by the student body.
Using the honor code, if one exists, to clearly define the role of plagiarism can help students understand what is expected of them in this domain.
Remediation
Remediation depends in large measure on the type of plagiarism that has occurred. Serious cases involving the scientific integrity of a piece of work by stealing another’s ideas and representing them as one’s own should be dealt with by considering failure in a course, clinical rotation and in some cases, dismissal from school.
Plagiarism of any sort is a serious offense, whether premeditated or inadvertent. Remediation is often more successful if the trainee has a clear sense of what rule or norm has been violated and what its present and future impact may be. Using literary examples like the historian Stephen Ambrose whose otherwise unblemished career was sullied when it was discovered that he had plagiarized his own and others’ works in his books are useful in bringing plagiarism issues to the forefront.
It may also be useful to bring attention to the link between unprofessional behavior of undergraduate medical students, including plagiarism, and risk of subsequent censure by state boards of medical practice.
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Another challenge for professionalism training is boundary management. Although there are dimensions of boundary management that touch upon the use of social media, for example, whether it is appropriate for physicians to be “friends” with their patients on Facebook, or First Amendment issues of whether schools or residency programs have the right or obligation to monitor their trainees’ individual postings, students and residents also confront a range of boundary issues in their day-to-day work and roles. Little attention is paid to these issues in the formal professionalism curriculum, because the issues are not recognized or do not fit well into the global categories of professionalism such as altruism, beneficence, or humanism. In addition, abstract discussions of professionalism often exclude issues of power and hierarchy which dominate many students’ thinking and experience. A particular challenge in this regard is the transition from classroom learning, which typically takes place in the first and second year of medical school, to clinical rotations where classroom learning is disregarded or derided. Students are often left on their own to piece together the appropriate boundaries of their professional role in regard to patients, peers, allied health professionals, and teachers while realizing that they are often at the lower rungs of power and potentially vulnerable to negative evaluations should they incorrectly define their professional role.
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CASE ILLUSTRATION 3: MANAGING PROFESSIONAL AND PERSONAL BOUNDARIES Scenario 1
An intern went out of his way to ‘warn’ the members of our team that a particular. . [professional] working with us was ‘an idiot’ . . I thought this was extremely disrespectful to the [professional], who was unaware of any of this . . I wanted to say something but I wasn’t sure if that was my place. I had no idea how to handle the situation. (Narrative written by a third year medical student.)
Medical students frequently struggle with the concept of professional boundaries, especially as it relates to their role in hierarchical situations. On their clinical rotations, and in their role primarily as observers, students often witness behaviors in others which they perceive to be unprofessional but feel powerless to address. Fear of reprisal, loss of face among peers, and being labeled a “whistleblower” or a troublemaker are frequent reasons given by medical students for failing to act in the face of behavior perceived to be unprofessional. In these cases, as illustrated above, boundaries defined by power differentials may be particularly difficult for students to navigate. Especially troubling to medical students are situations that involve disrespect. Boundaries are not specifically included in the Association of American Medical Colleges (AAMC) professionalism categories, but can be considered proxy measures for concerns about personal and professional conduct.
CASE ILLUSTRATION 3 (CONTD.) SCENARIO 2 I was sitting in the conference room when the assistant came in and said, ‘You have a patient in the exam room who is going to make your day.’ I walked in and this woman is dressed in like a wet tee-shirt, no bra, very good looking and shapely. I started talking to her and she was giggling every other word and acting more inappropriately than I’m used to . . And it was very uncomfortable because I was sitting in that room looking at her and I couldn’t divert my attention from looking at her breasts. I tried to spend a lot of time looking down at her chart, but every time I looked up my eyes zoomed in on her breasts. She was controlling my eyes … jiggling those things around so that her already prominent breasts were more prominent…She was just too flirtatious for me. I was really uncomfortable. (Third-year resident)
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Sexuality and sexual feelings are a normal part of being human. Sexual feelings between a doctor and patient are not abnormal, but they can sometimes be confusing and troublesome. When acted upon, they can be dangerous to the relationship and potentially exploitative. In previous research based on the narratives of students, residents, and practicing physicians, we found that the majority of situations in which providers’ sexual feelings came into play involved boundary confusion on the physician’s part. These situations typically involved their recognition of a sexual attraction or the potential for becoming aroused during the medical visit. Very infrequently, the feelings led to a boundary crossing where physician and patient mutually disclosed their feelings of attraction to one another. Much more frequently, the physician took steps to avoid the feelings by fleeing the encounter or skipping portions of the physical examination. Both male and female physicians described failing to do rectal, genitourinary (GU), and breast examinations to avoid boundary confusion. The above narrative from a third-year resident in internal medicine graphically illustrates the effect sexual feelings and assumptions about others’ behavior can have on the medical encounter.
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It is clear from this narrative that the patient’s appearance and manner of interacting (inappropriately described by the assistant as “a patient who’s going to make your day”) led the resident to “sexualize” the situation and make some assumptions about the patient, her behavior, and her intentions. He then became caught and confused between the nature and boundaries of the doctor–patient interaction, and those of an encounter between himself as a sexually interested man and an attractive woman. It is interesting to note that the resident did not recognize his own role in nonverbally encouraging the very behavior that made him so uncomfortable. He reported that each time he looked up, his eyes zoomed in on her breasts, the result of which he felt was to make her display them even more prominently. The resident was clearly stuck, attracted to his patient, and at the same time struggling to distance himself sufficiently to maintain an appropriate professional boundary. He knew something was wrong, but was not sure what it was, or what to do about it. This sense of helplessness and lack of clarity is typical of confusing boundary situations.
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As it happens, our resident is not alone in feeling a confusing attraction to his patient. Prior research among psychiatry residents has found that most men and about half of the women reported sexual attraction to one or more patients, and 1% acknowledged sexual contact with patients. Another study found that 57% of medical students had sexual feelings about patients, and that males had them more frequently than female students. Twenty-one percent of the students surveyed thought it was okay to have sex with patients. The same study reported that there was no teaching in the undergraduate curriculum about sexual boundaries in medical care.
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Educational and Institutional Implications
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Formal/Informal Curriculum
Faculty Development
Faculty members are often unaware of how their behavior affects students and residents. Strong emotions such as frustration, anger, and contempt are amplified among students and residents who view themselves in a “one down” position. Relational coordination and safety in the learning environment suffer when students feel intimidated or humiliated.
Faculty development programs that emphasize new rules and regulations with zero tolerance for disruptive behavior, mistreatment of trainees, or sexual boundary violations can help inform faculty members and raise awareness.
Opportunities to practice skills of maintaining healthy boundaries with peers can help surface personal and professional boundary issues that were never taught in medical school or residency. Working through cases with peers helps to create a culture of respect among faculty with a “trickle down” effect on residents and students.
Faculty development courses such as the ones put on by the American Academy on Communication in Healthcare use skill development and personal awareness together to teach faculty how to create a safe, satisfying learning environment for trainees and how to recognize and deal effectively with sexual and other boundary issues.
Institutional Response
Remediation
Remediation for students who have engaged in unprofessional behavior that threatens or crosses personal or professional boundaries should be handled on a case-by-case basis. Obviously, remediation will depend on the seriousness of the boundary issue in question. Consequences, too, will vary from dismissal from medical school to learning about the risks of boundary confusion, boundary crossings, and boundary violations.
If it is determined that the boundary issue is one in which there is a deficit in performance, suitable remediation might include activities such as: coaching and role play; research on the causes and consequences of boundary issues in medical students and residents; developing and presenting a teaching module to peers on professional boundaries; counseling and psychotherapy; and close supervision by faculty during clinical rotations.
If it is determined that the boundary issue is due to an impairment, steps should be taken to alert institutional representatives who are prepared to deal with such issues.