46: Educating for Professionalism

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.

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.

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.

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.

Social Media

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.

Educational and Institutional Implications

1. 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.

     • Education can be effective. One school that developed an educational intervention around Internet privacy saw an 85% drop in publicly available Facebook pages.

   • 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.

2. Faculty Development

   • Inappropriate use of social media among faculty has increased as evidenced by a recent flurry of articles in the popular press and a study of the actions of state medical boards dealing with this issue.

     • Faculty development programs focusing on the use and abuse of social media by students and colleagues can be helpful in raising awareness of the risks involved.

     • Encouraging faculty to lead by example in the use of smart phones and other handheld devices can also be effective in addressing inappropriate usage.

3. 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.

4. 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.

Plagiarism

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.

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.

Educational and Institutional Implications

1. Formal/Informal Curriculum

   • Plagiarism may occur in many forms in preclinical and clinical contexts.

     • It is not safe to assume that students and residents would have learned about plagiarism in college. Consequently, formal instruction on the various types of plagiarism in medicine can help trainees be aware of what is and what is not considered plagiarism.

     • Certification may be another alternative for teaching about plagiarism. In the same way that researchers must obtain human subjects certification to do their work, trainees would have to complete one or more modules on plagiarism and become “certified.” This would ensure that subsequent plagiarism breaches could not be attributed to sheer lack of knowledge and would make clearer to students the consequences of such actions.

     • Use of informal channels such as reviewing articles in a journal club format, brown bag discussions, or “Ethics at Lunch,” led by students with input from faculty advisors, can be a useful avenue for raising awareness about falsification and plagiarism.

2. 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.

3. 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.

4. 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.

Boundary Management

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.

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.

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.

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.

Educational and Institutional Implications

1. Formal/Informal Curriculum

   • Both students and residents find it difficult to act in the face of witnessing unprofessional behavior or experiencing sexual feelings that could threaten or cross boundaries.

     • Curriculum offerings that focus on duty, responsibility, and accountability can help trainees define boundaries so that they have a clear understanding of the issues involved.

     • Curricula should discuss physical and sexual boundaries with patients, peers, and faculty. Role-plays could address ways to respond to sexual confusion or boundary transgressions. Clear legal and ethical ramifications should be discussed.

     • Communication skills for dealing with conflict, especially where there is an authority gradient, can be helpful in giving students and residents the requisite skill set to successfully address boundary crossings and violations.

     • Curriculum content that reinforces the consequences of boundary confusion, crossing, or violations for patient safety and quality can help raise awareness of the larger issues that underlie professionalism. For example, using evidence to show that disruptive surgeons have worse complication rates and are more likely to be sued frames unprofessional behavior as a risk rather than a personality trait.

     • Looking for positive examples of maintaining healthy sexual and other boundaries among students, residents, and faculty can also be helpful in terms of reinforcing desired norms in the informal curriculum.

2. 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.

3. Institutional Response

   • Clear institutional policies for dealing with boundary concerns and violations are critical to creating safe, supportive work environments.

     • Having personnel and procedures in place for faculty and trainees to present their concerns, have them investigated and hopefully resolved in a nonjudgmental way can help reinforce both the informal and formal curriculum.

     • Orientation programs for entering medical students, residents, and fellows with opportunities for small group discussion and role play can be helpful in putting the issues of healthy boundaries in a positive, constructive light. Similar programs are useful in orienting new faculty and staff.

4. 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.

In this chapter, we have tried to bring to light some of the most pressing professionalism issues that trainees encounter. Although global concepts like altruism, respect, and equity are enormously helpful in setting community or disciplinary standards of behavior, the lived experience of medical students and residents is much more tightly bound to the local cultures and contexts in which they live and work. One of the most important aspects of educating for professionalism is to build bridges between students’ experiences in the informal curriculum and the global concepts they represent.

One pedagogical and practical challenge is to remain nonjudgmental about the behaviors observed in, or reported by, students and residents. It is very easy to slip into the role of moral arbiter in situations in which unprofessional behavior is being discussed. The surgeon who yelled at a student or the attending who admonished a patient to lose weight may have had good reasons for doing so (e.g., the student was about to break the sterile field, and the patient had dangerously high blood pressure and was at imminent risk of a heart attack). Rather than acting on the student’s or resident’s behalf in the face of a reported boundary issue, helping trainees to develop their own skill set for dealing with the behavior, and closely monitoring their progress can be very fruitful. Obviously, if there is suspicion that the issue represents a boundary violation with potential for harm to the trainee, immediate action and fact finding may be required.

At the student level, professionalism challenges tend to be recurrent; caring, compassion and communication (especially across an authority gradient), respect, and teamwork tend to dominate the concerns. For residents, autonomy, conflicts of interest, and mistakes take on special importance. For both students and residents, boundary issues, albeit different for each group, tend to occur with great frequency in professionalism discussions.

Pedagogically it is helpful to start with trainees’ lived experiences of professionalism and deepen reflection on them through small group discussion, use of student narratives, and facilitated faculty discussion. This approach optimizes the likelihood of making professionalism education salient and engaging for both students and faculty. Discussions of topics like medical mistakes, boundary issues, sexuality and professionalism, impaired physicians, quality and safety, and conflicts of interest can help highlight and deepen trainees’ understanding of their own and others’ behavior and reinforce the value of professionalism to the individual, community, and society. From a practical point of view, focusing on professionalism as a way of being rather than an abstract set of concepts helps trainees make connections between their existence in the real time environments in which they are training and their hopes, dreams, and aspirations for their lives in the profession of medicine.

American Academy on Communication in Healthcare. http://www.aachonline.org/. Accessed February 2014.

ABIM Project Professionalism. http://www.abimfoundation.org/en/Resource%20Center/Bibliography/~/media/Files/Resource%20Center/Project%20professionalism.ashx. Accessed February 2014.

AMA Position Statement on Medical Professionalism. http://ama.com.au/node/5449. Accessed February 2014.

Annals of Internal Medicine Physician Charter on medical professionalism. http://annals.org/article.aspx?volume=136&issue=3&page=243. Accessed February 2014.

American College of Physicians: Medical Ethics and Professionalism Cases. http://www.acponline.org/running_practice/ethics/. Accessed February 2014.