Chapter 11: WHEN THINGS GO WRONG: THE CHALLENGE OF SELF-REGULATION

LEARNING OBJECTIVES

1. To describe the nature and frequency of professionalism lapses.

2. To explain the impact of unprofessional behavior on patients, students, and the healthcare team.

3. To identify why professionalism lapses occur.

4. To illustrate how most individuals who witness lapses respond to them.

5. To outline strategies to respond to a spectrum of professionalism lapses.

INTRODUCTION

In today's complex and often chaotic environment, physicians are often challenged as they strive to live their professional values. Physicians may struggleto maintain their equanimity in the face of suffering and dying patients, heightened productivity demands, work-related fatigue, and distressed colleagues. As humans, we may also be dealing with struggles outside of work. Physicians are not immune to personal illness, relationship troubles, or distractions related to dependent children or parents.Rather than be surprised that lapses in professionalism occur, we should anticipate that they will occur and prepare to handle them in a way that honors the trust that society places in both individual physicians and the collective profession when they grant us the privilege of self-regulation.

Unfortunately, individually or collectively we do not always live up to this commitment. Highly publicized incidents of physicians as the perpetrators of crimes against society, ranging from financial fraud to sexual assault to even more egregious crimes are rare. When they occur, however, they raise questions about how the medical profession could have let someone with this flawed character enter or remain within the profession (Stewart, 2000). More common are examples of ethical transgressions, such as research- or practice-based conflicts of interest, where physicians have placed their financial or career success ahead of the best interests of their patients (Brownlee, 2008). Even more common are the type of professionalism lapses that don’t make headlines, but that pervasively undermine the culture of respect that is essential to the effective functioning of our patient care and educational environments (Leape et al, 2012a; Walrath, Dang, & Nybert, 2013; Wear et al, 2009; Hickson et al, 2007; Samenow et al, 2013; Silverman et al, 2012). These include the daily incivilities that occur in the workplace and are characterized by disrespectful language, dysfunctional relationships, disregard of policies and procedures, and dismissive or destructive responses to clinical disagreement or uncertainty. Figure 11-1 describes these different types of breaches of professionalism.

WHAT DO PROFESSIONALISM LAPSES LOOK LIKE AND HOW COMMONLY DO THEY OCCUR?

Because unprofessional behavior covers a spectrum of actions that range from lapses to transgressions to crimes, it is difficult to pinpoint the frequency of professionalism lapses. The literature relevant to understanding these lapses can be found not only in articles that specifically address professionalism (Hickson et al, 2007; Teherani et al, 2005; Adams, Emmons, & Romm, 2008; Campbell et al, 2007; Buchanan et al, 2012; ...