Rx Dose of Reality: Using Real Disciplinary Cases to Teach Ethics and Professionalism in Residency

Setting and Problem

Professionalism lapses remain one of the most common causes of disciplinary actions by state medical boards. Yet residents often graduate without understanding how everyday decisions can lead to sanctions, loss of license, or even criminal charges.¹ Residency programs consistently face challenges in addressing professionalism lapses among trainees due to the perceived subjectivity of lapses, defensiveness to correction within power hierarchies, and limited empowerment or structured opportunities for reflection and discussion.² Traditional professionalism education often focuses on abstract ethical principles, offering a limited connection to the real-world consequences of unprofessional behavior.

At our university-affiliated 6-6-6 family medicine residency program, residents viewed professionalism sessions as repetitive and disconnected from clinical reality. They expressed limited familiarity with disciplinary processes, mandated reporting, and the range of possible board actions. We sought an approach to make ethics relevant and memorable by connecting abstract principles to real physician cases and consequences, while engaging the modern learner through real-world media and discussion-based learning.

Intervention

Launched in 2023, Rx Dose of Reality is a case-based curriculum that teaches ethics and professionalism through real physician disciplinary cases. Each 30- to 60-minute session features a video or written summary from publicly available Arkansas State Medical Board hearings (livestreamed on YouTube), federal court cases, published misconduct reports, or anonymized residency-based scenarios drawn from faculty experience.

Topics covered include fraudulent billing, documentation falsification, substance misuse, sexual misconduct, social media HIPAA violations, and failure to report abuse. Cases may be used to identify a law that residents are unaware of or an ethical dilemma that led to disciplinary actions. With the ethical dilemma scenario(s), residents apply a 5-question structured framework to the ethical dilemma after reviewing:

1. What are the benefits and risks for my patients with this decision?

2. What are the personal and professional risks for me?

3. Will this decision violate ethical or legal standards?

4. What preventive actions could have changed the outcome?

5. What would I do differently in this situation?

Facilitated discussions link each case to a relevant ACGME core competency. Residents predict potential disciplinary outcomes, then compare them to actual board decisions. Faculty emphasize during sessions that lapses often arise from everyday pressures such as burnout and ignorance of policy and the law. Using real disciplinary cases reframes professionalism education as experiential learning grounded in authentic, high-stakes examples. A case example is included in the Table.

Table.

Summation of Residents’ Reflections Using the Structured Ethical Framework in a Boundary Ambiguity Case Involving Informal Care Provided in a Social Setting

Reflection Prompt	Summation of Residents’ Reflections
Benefits and risks for the patient	Although intended to reduce medical costs, the informal examination in a private home and required exposure created discomfort and confusion about the relationship, potentially undermining trust and emotional safety.
Personal and professional risks	Providing medical care outside a clinical setting blurred professional boundaries and exposed the physician to allegations of misconduct and licensure risk, even without sexual intent.
Ethical or legal standards	Residents identified concerns related to dual relationships, lack of documentation, and failure to maintain clear professional boundaries when providing care in a social context.
Preventive actions	Residents noted that referring the individual to urgent care or declining hands-on evaluation outside a clinical setting would have reduced boundary ambiguity and professional risk.
What would be done differently	Residents stated they would avoid providing medical care to friends, former patients, or acquaintances in social settings and would clearly separate personal and professional roles.

Outcomes to Date

Since 2023, Rx Dose of Reality has been implemented across 3 residency classes. Residents frequently expressed surprise at the scope of disciplinary issues and the specific standards set by medical boards. They reported that the realism and “drama factor” made professionalism “feel real and more important,” helped them recognize ethical dilemmas they had not previously considered, and gave them a more structured way to approach uncertain decisions. They reported a clearer understanding of disciplinary processes and legal implications.

Feasibility is high. Faculty preparation time is typically limited to 1 to 2 hours per session, as cases are drawn from publicly available sources and integrated into existing didactic time. The curriculum requires no external funding and can be readily adapted to other specialties by substituting local or specialty-specific cases.

Rx Dose of Reality serves as a practical and adaptable component of a professionalism curriculum, offering a structured approach that brings professional identity formation to life. By grounding ethics education in real-world contexts, this model promotes engagement, reflection, and accountability while preparing residents to uphold patient safety, professional integrity, and public trust throughout their careers.