Responding to moderate breaches in professionalism: An intervention for medical students

Abstract

Much has been written about how we understand, teach and evaluate professionalism in medical training. Less often described are explicit responses to mild or moderate professionalism concerns in medical students. To address this need, Baylor College of Medicine created a mechanism to assess professionalism competency for medical students and policies to address breaches in professional behavior. This article describes the development of an intervention using a guided reflection model, student responses to the intervention, and how the program evolved into a credible resource for deans and other educational leaders.

Introduction

Physician experiences in medical school influence habits of mind and behavior that can have a lasting impact on professional behavior (Epstein 1999; Stern 2000; Stern & Papadakis 2006; Epstein et al. 2008). Researchers have found that students with reported concerns of unprofessional behavior may be at risk of disciplinary action as practicing physicians (Papadakis et al. 2004, 2005). Early identification and intervention may help to re-direct students and prevent future disciplinary problems (Dyrbye et al. 2010; Roff & Dherwani 2011); however, reporting mechanisms must be in place to identify and remediate lapses in professional behavior (Cruess & Cruess 2008). While major breaches in professional behavior are often swiftly reported and remediated, faculty and staff are hesitant to report mild to moderate breaches in student behavior due to concerns that the breach does not rise to the level of reporting to a dean; or fears that the consequences of reporting will have a negative impact on the teacher–learner relationship.

The Liaison Committee on Medical Education (LCME 2013) requires medical schools to have processes in place to identify and report unprofessional behavior, but those processes can vary among institutions. To be successful, reporting must not be tedious or burdensome and confidence in the process must be assured. Many programs have described their systems or processes for identifying serious or significant professional concerns (Papadakis et al. 1999; Arnold 2002; Hickson et al. 2007; Goldie 2013). However, less has been reported describing the process for remediating mild to moderate infractions. The purpose of this article is to describe the development, implementation and process for addressing mild to moderate breaches in professional behavior at Baylor College of Medicine (BCM).

How we started

In 2005, the leadership of BCM empowered a task force to identify and report on the state of professionalism education, assessment and remediation in undergraduate medical education. Following two years of literature review, examining best practices, and engaging stakeholders, the Professionalism Appraisal and Competency Evaluation Committee (PACE) was created to implement a standardized process to identify, report, and respond to concerns of unprofessional behavior in medical students. Policies and processes were developed to formally assess professionalism in the preclinical and clinical curriculum and to capture breaches in behavior in institutional environments external to the classroom or clinic (e.g. library, occupational health, administrative offices; Swick 2007). Anyone with a BCM e-mail address can report unprofessional behavior using the online Report a Professionalism Concern. This link captures and records the concerns in a confidential, restricted database. In addition to providing the details of the event, the reporter must link the reported professionalism breach to all applicable BCM professionalism competencies that were not met from a checklist. The BCM professionalism competencies were developed by representative faculty from across the institutional enterprise. Modeled upon the Accreditation Council for Graduate Medical Education (ACGME) competencies, BCM professionalism competencies represent consensus physician professional behaviors. Once reported, an automatic e-mail is generated to the PACE Chair who forwards the concern to the five member Rapid Response Team (RRT).

The RRT is currently comprised of a JD/PhD ethicist, a PhD in the basic sciences, a psychiatrist, a pediatrician and a public health professional. The chair of the committee identifies and recruits faculty for the RRT with input from the Deans. We specifically look for faculty with some training in ethics and/or medical professionalism and who are respected for their integrity and collegial interactions. We also strive for diversity in gender and race/ethnicity along with balance in senior faculty with protected time and junior faculty on an education promotion track. Members are appointed to a four-year term but may be reappointed. During the first year of operations, the RRT recognized the need to include a member on the team with training in the behavioral sciences who could better identify students that would potentially benefit from mental health services. Therefore, while all members of the RRT bring important perspective to the work of the committee, the only prescribed member is a psychiatry or psychology representative.

Upon receiving the reported concern all five members of the RRT independently rank the reported professionalism concern as mild, moderate or major. A mild concern is a low-level issue that does not need immediate intervention and is tracked and followed over time (e.g. failing to complete course evaluations or complying with immunization requirements by the due date). Erring on the side of caution, to qualify as a “mild” professionalism concern the ranking must be unanimous. If no additional concerns are reported during medical school, the student may never know a report has been filed. If a student receives a second mild concern it is automatically classified as moderate. Moderate concerns carry a higher level of significance (e.g. texting friends during a clinical encounter, wearing ear buds during small group discussions) and are further reviewed by the RRT. These moderate concerns most often result in a face-to face meeting with the student. A major concern is usually self-evident (e.g. cheating on tests, substance abuse) and is immediately reported to the Dean of Student Affairs.

While methods of ranking reported concerns of student behaviors have been previously reported in the literature (Smith et al. 2007; O’Sullivan & Toohey 2008; Van Mook et al. 2009), many of those described rankings are performed by one or two faculty in the office of student affairs. Our system offers the benefit of more perspectives and lessens the individual burden of doubt and second-guessing decisions.

Once a concern is ranked as moderate, a mandatory meeting is set up for the student and the RRT. The student is contacted by e-mail two days prior to the meeting with the intent to ensure ample notice but not provoke undue anxiety in the interim. Students confirm their planned attendance; however, the meeting may be rescheduled if the student is unavailable or needs more time to prepare. Contextual information such as time, place, course or clerkship and a general description of the reported concern are provided to the student for reference. Thereafter, some students may attempt to “mount a defense” via e-mail and may need to be reminded that the meeting is exploratory about a lower level professional concern and that the RRT has no decanal authority. Additional efforts to prepare students and reduce anxiety include notification of who will be attending, the format and length of the meeting, and discretion to discuss with their mentor (an appointed faculty member who provides individualized student guidance throughout all four years of medical school). Efforts are made to schedule the meeting when all five RRT team members are available, but a quorum of three is required.

The meeting typically occurs during the noon hour in a discreet location that reduces the likelihood of being discovered by classmates or other medical students. The RRT assumes a student-friendly, non judgmental position during the interview process as evidenced by open and positive body language (Taylor et al. 2011). Faculty members introduce themselves and inform the student that the meeting will remain confidential to the extent possible (i.e. no one without a compelling need to know will be informed that a meeting has occurred or what was discussed). Occasionally, the RRT becomes involved in a case at the request of a Dean. Should that happen, the student is informed that a follow-up report will be submitted to the Dean, but otherwise confidentiality will be maintained.

The RRT asks the student to consider the conversation as similar to a discussion with a big brother or sister to establish a positive and non-judgmental atmosphere. The student is asked to share something about his or her career goals or medical training. The ground rules and goals of the interview are explained (Table 1), and the reported concern that triggered the meeting is reviewed.

Table 1.

Intervention process for moderate professional concerns.

Introductions	Members of the RRT, academic roles, student; class and career goals
	PACE role and responsibilities
Purpose of meeting	What triggered the meeting? Multiple mild reports, a moderate report or Dean’s request
Ground rules	This is a safe place
	Confidentiality and limitations
	RRT is a student resource
Student story	Student provides their version of events
Reflections questions	What were the contributing factors?
	What were your thoughts at the time?
	How do you think this would impact others?
	How did this impact you?
	What did you learn from this event?
Professionalism competency	Which professionalism competency was or was not met?
	How will you respond to a similar situation in the future?
	What strategies will you employ?
	What resources will help you move forward?
	What are your concerns now?
Closing	Offer praise for positive movement
	Identify additional resources and continued support
	Future acknowledgement at student imitative
	Next steps

Next the student is invited to share his or her version of the event. If a breach of professional behavior is apparent, the RRT will assess the student’s acknowledgement and ownership of his or her actions. Students who readily admit culpability are encouraged to reflect upon the factors both internal and external that contributed to the beach in professional behavior. Emotional responses may be expressed and acknowledged. Lessons learned are shared and strategies to prevent future breaches are discussed until the student appears ready to move on.

Students are given a copy of the BCM professionalism competencies and asked to identify the professionalism goals which may or may not have been met. This serves two purposes; it clearly frames the event within the context of professionalism, and allows the students to assess their actions and behaviors to a standard (Goldie 2012). Before adjourning, the RRT asks the student to share ongoing concerns and offers praise for any forward movement. Students are encouraged to utilize college resources as needed (including the RRT faculty) and next steps are outlined. After the student leaves the room, the RRT members debrief and share their impressions. Notes from the meeting are recorded in a secure and restricted database. If no other breaches are reported about the student, no other actions ensue.

There are very rare cases when a student fails to either recognize an obvious breach or accept responsibility for the behavior. As irresponsibility and a diminished capacity for self-improvement have been associated with unprofessional behavior (Papadakis et al. 2005), this response may lead to a higher ranking and a report to the Dean of Student Affairs.

Results

Over a five-year period (2008–2013, ~700 students per year), the RRT received 79 reported concerns and conducted 20 student interviews. Only one of these students went on to have additional professionalism concerns reported. As intended, 55% of all reported concerns were mild or had already been addressed by the course or clerkship director and were reported to track and follow only. In most cases the student is not told that a mild concern has been reported, unless informing the student of the reported concern is likely to result in corrective action. For example, a student who may be reported to the RRT due to repeated tardiness during exams may continue to be late if they do not realize they are being monitored. In those cases an e-mail is sent notifying the student that a report has been received and why.

Males accounted for 65% of the reported professionalism concerns which were evenly distributed amongst all four class years. Most of the concerns were reported by faculty (65%) however, students have increasingly begun to use the reporting system as it has gained increased visibility and acceptance and now student reporting accounts for 8% of all reported concerns. Of the 16 major concerns reported to the RRT, many were already known to the deans, and had been reported to the RRT for completeness or due to uncertainty on the part of the reporter. Regardless, this reporting mechanism provides a redundancy that ensures concerns do not go unreported or “fall through” the cracks.

The average number of identified professionalism competency breaches for each reported concern was three. The most frequently cited breach was associated with fulfilling responsibilities and obligations as a learner and a colleague (22%). Recognizing and avoiding conflicts of interest was cited least often (1%).

The RRT’s contributions have become appreciated and valued by the deans. Over time, the RRT has been increasingly consulted to interview students and advise them on difficult cases with major professional concerns such as Health Insurance Portability and Accountability Act (HIPAA) violations, social media infractions, and academic integrity. The success of the RRT has become a model for a similar resident professionalism committee now in development.

What’s next?

Implementation and lessons learned

The processes at BCM were developed in an iterative trial and error fashion. Of interest is that our RRT interview process has organically emerged to resemble established guided reflection models described in the literature (Rees & Knight 2008). As we gain more experience as a committee, we continue to critically review and revise our processes. The RRT was intentionally designed not to prescribe remediation or disciplinary action (which is the purview of the deans); therefore, there is some risk that students may discount an intervention as not having real consequence. However, our positive, non-judgmental and student-centered focus usually results in sentiments of appreciation from the student.

Another limitation of the RRT is occasional confusion over its role of investigation versus intervention. For example, a student may accuse a classmate of being intimidating or threatening violence. This would be classified a major concern, but without corroboration, the decision to report the matter to the deans can feel premature. The natural tendency is to want to gather “proof” of the transgression, when in fact, that would be the responsibility of the Dean and outside the committee’s purview.

One unintended positive consequence of the RRT has been its emergence as a credible resource for both policy making (e.g. slow administrative compliance is a reportable concern) and decisional support to the deans in undergraduate medical education and student affairs. Today’s deans must balance their responsibility as fiduciaries of a public trust, while functioning as a student advocate and champion. Without a crystal ball, no one can predicate with certainty which medical student is remediable and which one will continue to behave unprofessionally. As mentioned above, even though the RRT is charged with tracking and following mild to moderate professionalism concerns, the RRT has been consulted by the deans to interview and render opinions in cases where students have committed major professional breaches. Input from the RRT provides an additional source of information to the deans and promotions committee when making difficult decisions with significant consequences.

As stated previously, the RRT does not discuss student interventions with coworkers or anyone else without a clear “need to know.” The trust and collegial bonds forged by such an intervention strategy enables RRT group cohesion and enhances the reputation of the professionalism process with students, faculty and deans. Moreover, debriefing discussions within the RRT furthers the evolution of the intervention process. The general experiences of the RRT, without providing explicit details or breaking student confidentiality, are reported to the PACE Advisory Committee for the purpose of transparency and accountability.

This article contributes to the medical literature by describing one process for ranking and intervening with mild or moderate professionalism concerns before they become ingrained habits. We have developed a credible process for ranking medical student reported professional concerns which previously had been overlooked, ignored, or viewed in isolation. The intervention of the RRT is designed to attenuate behavioral patterns that may progress to more significant breaches and provides additional assurances and support to the college leadership. More research from the behavioral and social sciences describing interventions that lead to sustained and long-lasting behavioral change in medical trainees is needed to enhance the long-term effectiveness of intervention practices.

Practice points.

• Mild to moderate breaches of professional behavior in medical students may go uncorrected due to multiple factors

• Professional behaviors are inculcated and reinforced in medical school becoming the foundation for future practice

• Guided reflection may help students gain insight and perspective

• Early intervention may prevent future professional breaches