Bad Behavior by Medical Trainees Target of New Proposal

Marcia Frellick

February 28, 2020

Some instances of unprofessional behavior by medical trainees are universally deemed egregious and worthy of discipline — for example, looking up a friend's medical data after HIPAA training.

Conversely, some professionalism lapses may be widely thought of as a teaching and consoling moment, such as the human error involved in forgetting a scheduled repositioning of a patient.

But between the extremes is a vast gray area. To deal with those cases appropriately, Jason Wasserman, PhD, and colleagues propose a new framework by which to judge each infraction.

The framework draws from "just culture" concepts used to evaluate medical errors, Wasserman, associate professor of biomedical science at Oakland University William Beaumont School of Medicine in Rochester, Michigan, told Medscape Medical News. Such an approach takes into account the environment in which the error was made, the knowledge and intent of the person making the error, and the severity and consequences of the infraction so that trainees and institutions can learn from mistakes.

"Trainees by definition are not going to fully get it," he explained. "By definition they're not going to fully achieve professional expectations. So how can we respond to the things we need to respond to, but do it in a way that's educational?"

Wasserman and coauthors' framework for remediation, which they published February 20 in The New England Journal of Medicine, takes into account several questions: Was the expectation clear? Were there factors beyond the trainees' control? What were the trainees' intentions and did they understand the consequences? Did the person genuinely believe the action was inconsequential?

An example requiring discipline, the authors say, would be using a crib sheet during an exam. In that case the intent is clear, there is no defensible belief that the action is inconsequential, and there is a clear understanding the action is wrong.

But a response of "affirm, support, and advise" is more appropriate, for example, when a student's alarm doesn't go off after a power outage and they miss a mandatory meeting.

Wasserman points out that this framework won't cover all situations.

"This is not an algorithm for answering your questions about what to do," he said. "It's an architecture for clarifying the discussion about that. It can really tease out all the threads that need to be considered to best respond to and correct the professionalism lapse, but do it in a way that is developmentally appropriate."

A Core Competency

For two decades, professionalism has been considered a core competency of medical education. In 1999, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties formalized it as such. In 2013, the Association of American Medical Colleges formally required related professionalism competencies.

However, identifying lapses has operated largely on an "I-know-it-when-I-see-it" basis, leading to widely varying remediation practices judged by a small number of faculty members or administrators.

The ideas outlined by Wasserman and colleagues are "a terrific application of the 'just-culture' framework," according to Nicole Treadway, MD, a first-year primary care resident at Emory School of Medicine in Atlanta, Georgia.

At Emory, discussions of professionalism start from day 1 of medical school and the subject is revisited throughout training in small groups, Treadway told Medscape Medical News.

But, she said, as the authors point out, definitions of unprofessionalism are not always clear and the examples the authors put forward help put lapses in context.

The framework also allows for looking at mistakes in light of the stress trainees encounter and the greater chance of making a professionalism error in those situations, she noted.

In her own work, she says, because she is juggling both inpatient and outpatient care, she is finding it is easy to get behind on correspondence or communicating lab results or having follow-up conversations.

Those delays could be seen as lapses in professionalism, but under this framework, there may be system solutions or training opportunities to consider.

"We do need this organizational architecture, and I think it could serve us well in really helping us identify and appropriately respond to what we see regarding professionalism," she said.

Framework Helps Standardize Thinking

She said having a universal framework also helps because while standards of professionalism are easier to monitor in a single medical school, when students scatter to other hospitals for clinical training, those hospitals may have different professionalism standards.

Wasserman agrees, saying, "This could be easily adopted in any environment where people deal with professionalism lapses. I don't even think it's necessarily relegated to trainees. It's a great way to think about any kind of lapses, just as hospitals think about medical errors."

He said the next step is presenting the framework at various medical schools for feedback and research to see whether the framework improves processes.

Potential criticism, he said, might come from those who say such a construct avoids punishing students who make errors.

"There will always be people who say we're pandering to medical students whenever we worry about the learning environment," he said. "There are old-school purists who say when people screw up you should punish them."

But he adds healthcare broadly has moved past that thinking.

"People recognized 20 years ago or more from the standpoint of improving healthcare systems and safety that is a bad strategy. You'll never get error-free humans working in your system, and what you have to do is consider how the system is functioning and think about ways to optimize the system so people can be their best within it."

Wasserman and Treadway have disclosed no relevant financial relationships.

 N Engl J Med. 2020;382:773-777. Full text

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