Twelve tips for addressing medical student and resident physician lapses in professionalism

"Should I Say Something?": A Simulation Curriculum on Addressing Lapses in Professionalism to Improve Patient Safety

Introduction

Medical students may witness lapses in professionalism but lack tools to effectively address such episodes. Current professionalism curricula lack opportunities to practice communication skills in addressing professionalism lapses.

Methods

We designed a simulation curriculum to introduce professionalism expectations, provide communication tools using elements of the Agency for Healthcare Research and Quality TeamSTEPPS program, and address observed professionalism lapses involving patient safety in hierarchical patient care teams. Students were surveyed on knowledge, skills, and attitude regarding professionalism before, immediately after, and 6 months after participation.

Results

Of 253 students, 70 (28%) completed baseline and immediate postsurveys, and 39 (15%) completed all surveys. In immediate postsurveys, knowledge of communication tools (82% to 94%, p = .003) and empowerment to address residents (19% to 44%, p = .001) and attendings (15% to 39%, p < .001) increased. At 6 months, 96% of students reported witnessing a professionalism lapse.

Discussion

The curriculum was successful in reported gains in knowledge of communication tools and empowerment to address professionalism lapses, but few students reported using the techniques to address witnessed lapses in real life.

Post graduate remediation programs in medicine: a scoping review

BACKGROUND

Recognizing that physicians may struggle to achieve knowledge, skills, attitudes and or conduct at one or more stages during their training has highlighted the importance of the 'deliberate practice of improving performance through practising beyond one's comfort level under guidance'. However, variations in physician, program, contextual and healthcare and educational systems complicate efforts to create a consistent approach to remediation. Balancing the inevitable disparities in approaches and settings with the need for continuity and effective oversight of the remediation process, as well as the context and population specific nature of remediation, this review will scrutinise the remediation of physicians in training to better guide the design, structuring and oversight of new remediation programs.

METHODS

Krishna's Systematic Evidence Based Approach is adopted to guide this Systematic Scoping Review (SSR in SEBA) to enhance the transparency and reproducibility of this review. A structured search for articles on remediation programs for licenced physicians who have completed their pre-registration postings and who are in training positions published between 1st January 1990 and 31st December 2021 in PubMed, Scopus, ERIC, Google Scholar, PsycINFO, ASSIA, HMIC, DARE and Web of Science databases was carried out. The included articles were concurrently thematically and content analysed using SEBA's Split Approach. Similarities in the identified themes and categories were combined in the Jigsaw Perspective and compared with the tabulated summaries of included articles in the Funnelling Process to create the domains that will guide discussions.

RESULTS

The research team retrieved 5512 abstracts, reviewed 304 full-text articles and included 101 articles. The domains identified were characteristics, indications, frameworks, domains, enablers and barriers and unique features of remediation in licenced physicians in training programs.

CONCLUSION

Building upon our findings and guided by Hauer et al. approach to remediation and Taylor and Hamdy's Multi-theories Model, we proffer a theoretically grounded 7-stage evidence-based remediation framework to enhance understanding of remediation in licenced physicians in training programs. We believe this framework can guide program design and reframe remediation's role as an integral part of training programs and a source of support and professional, academic, research, interprofessional and personal development.

Tutor Uncertainty in Dealing with Unprofessional Behaviours of Medical Students and Residents: a Mixed Methods Study

BACKGROUND

Despite acknowledgement of medical students' expected professional behaviours and attitudes, there remains widespread reluctance to report students that behave inappropriately. Existing literature focuses on why faculty fail to fail, overlooking the tutors who deal with students day to day. We investigated how tutors address inappropriate behaviours and attitudes in students and residents.

METHODS

A mixed methods study was carried out consisting of a survey and two focus groups with tutors. Seventeen tutors from the University of Limerick School of Medicine, Ireland, took part in the survey (n = 22%) and eight tutors participated in two focus groups during the 2018-2019 academic year.

RESULTS

Findings suggested that 59% of tutors would take a different approach to addressing unprofessional behaviours witnessed in medical students and residents. A total of 88% of tutors said they intervened on a professionalism issue with 52% saying 'once in a while'. In contrast to the survey, tutors in the focus groups expressed a lack of confidence in addressing some behaviours due to a lack of time, not seeing the outcome of process/remediation etc. Tutors indicated a strong preference for case-based training on assessing professional identity formation (PIF).

CONCLUSIONS

We found tutors typically work closely with students on a day-to-day basis managing unprofessionalism issues. Tutors valued regular communication about policies and procedures about appropriate conduct as well as support, advice, and/or oversight from independent members of university staff. This research highlights the need for training designed for busy tutors as a distinct type of medical teacher.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01429-1.

Optimising the delivery of remediation programmes for doctors: A realist review

CONTEXT

Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety.

METHOD

We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs).

RESULTS

A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection.

CONCLUSION

Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review

Background

An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice.

Objectives

To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.

Design

A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group.

Review methods

Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations.

Results

A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection.

Limitations

Limitations were the low quality of included literature and limited number of UK-based studies.

Future work

Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS.

Study registration

This study is registered as PROSPERO CRD42018088779.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

How to identify, address and report students' unprofessional behaviour in medical school

This AMEE guide provides a research overview of the identification of, and responding to unprofessional behaviour in medical students. It is directed towards medical educators in preclinical and clinical undergraduate medical education. It aims to describe, clarify and categorize different types of unprofessional behaviours, highlighting students' unprofessional behaviour profiles and what they mean for further guidance. This facilitates identification, addressing, reporting and remediation of different types of unprofessional behaviour in different types of students in undergraduate medical education. Professionalism, professional behaviour and professional identity formation are three different viewpoints in medical education and research. Teaching and assessing professionalism, promoting professional identity formation, is the positive approach. An inevitable consequence is that teachers sometimes are confronted with unprofessional behaviour. When this happens, a complementary approach is needed. How to effectively respond to unprofessional behaviour deserves our attention, owing to the amount of time, effort and resources spent by teachers in managing unprofessional behaviour of medical students. Clinical and medical educators find it hard to address unprofessional behaviour and turn toward refraining from handling it, thus leading to the 'failure to fail' phenomenon. Finding the ways to describe and categorize observed unprofessional behaviour of students encourages teachers to take the appropriate actions.

Educator as Diagnostician, Judge and Confidant: a positioning analysis of medical student support encounters

Medical schools, programs and educators are increasingly expected to address medical student stress and wellbeing, yet also ensure student competence and fitness to practice. Educators play a central role in supporting students when evaluating a student's concerns and in deciding whether support and/or sanction should be offered. It is not known how educators approach or resolve such potentially contradictory responses. We conducted an interview study of 21 medical educators from a range of  professional backgrounds across 11 on-campus and clinical teaching sites. Using Positioning Theory to inform our thematic analysis, we found that participants adopted an overarching position of Diagnostician, and at times, two alternative positions, the Judge and the Confidant when supporting students. In their narratives of support encounters, individual students were positioned as Good Students or Troubling Students. For most, educator positions were fluid and responsive to the storylines enacted in encounters. Rigidly adopting Judge or Confidant positions could lead to "failure to fail" and violations of professional boundaries. Positioning Theory locates student support in a moral space and helps explain the consternation experienced by educators when support is not effective. Positioning analysis offers a language, and metaphors which are meaningful to educators, for framing discussion and reviews of support practices and progression decisions. Such insights could encourage reflective practice and guide further research to inform practice when students with troubling concerns and persistently borderline performances require support.

An Emergency Medicine Remediation Consult Service: Access to Expert Remediation Advice and Resources

Resident remediation is a complex and common issue in emergency medicine programs and requires a specific knowledge base. The Remediation Task Force (RTF) of the Council of Residency Directors in Emergency Medicine (CORD-EM) was created to identify remediation best practices and to develop tools for program directors. Initially housed on a Wiki page, and now located within the CORD-EM website, the RTF provides resources including accepted universal language for documentation and sample remediation plans. The RTF also created a remediation consult service composed of experienced educators to provide real-time structured feedback and advice to submitted remediation scenarios with consultation outcomes and conclusions uploaded to the website. CORD-EM members now have easy access to online resources and expert advice for remediation queries through the consult service. The combination of online resources and access to real-time expert advice is an innovative approach to improving resident remediation and recognizing best practices.

Motivational Advising Workshop: Utilizing Motivational Interviewing Theory to Facilitate and Engage Intrinsic Motivation to Change Learners' Behavior

INTRODUCTION

Motivational interviewing (MI) is a counseling method that utilizes a patient's own motivation to effect personal change. MI has been applied routinely and successfully to managing medical conditions (e.g., substance abuse). Employing MI techniques to engage medical learners (termed motivational advising [MA]) may help them overcome professional and/or personal challenges limiting their career development.

METHODS

Medical educators from four academic medical centers developed a module focused on teaching fellow educators MI theory and techniques for MA using didactic and interactive components. Participants participated in facilitated role-plays to practice MA delivery techniques and observed videos of a traditional advisor-advisee interaction as well as an MA-focused engagement. A postworkshop survey was used to evaluate the workshop.

RESULTS

In a survey of 48 educators attending the workshop at two medical conferences, over 80% of respondents demonstrated an interest in learning more about MA. Additionally, over 60% indicated that they would seek opportunities to practice and/or implement MA with their advisees. Knowledge of the technical components of MA also increased significantly in pre- and posttest analysis.

DISCUSSION

This module introducing the concept of MA was well received by medical educators and was viewed as a valuable tool in advising medical learners. The provided components enable replication of this workshop in other settings with or without an expert in MI techniques. Although the workshop has been conducted with physicians involved in medical education, it would be applicable to other health professionals who advise trainees such as nursing, dentistry, pharmacy, or veterinary medicine.

Self vs. Other Focus: Predicting Professionalism Remediation of Emergency Medicine Residents

Introduction

Unprofessionalism is a major reason for resident dismissal from training. Because of the high stakes involved, residents and educators alike would benefit from information predicting whether they might experience challenges related to this competency. Our objective was to correlate the outcome of professionalism-related remedial actions during residency with the predictor variable of resident response to a standardized interview question: “Why is Medicine important to you?”

Methods

We conducted a professional development quality improvement (QI) initiative to improve resident education and mentorship by achieving a better understanding of each resident’s reasons for valuing a career in medicine. This initiative entailed an interview administered to each resident beginning emergency medicine training at San Antonio Military Medical Center during 2006–2013. The interviews uniformly began with the standardized question “Why is Medicine important to you?” The residency program director documented a free-text summary of each response to this question, the accuracy of which was confirmed by the resident. We analyzed the text of each resident’s response after a review of the QI data suggested an association between responses and professionalism actions (retrospective cohort design). Two associate investigators blinded to all interview data, remedial actions, and resident identities categorized each text response as either self-focused (e.g., “I enjoy the challenge”) or other-focused (e.g., “I enjoy helping patients”). Additional de-identified data collected included demographics, and expressed personal importance of politics and religion. The primary outcome was a Clinical Competency Committee professionalism remedial action.

Results

Of 114 physicians starting residency during 2006–2013, 106 (93.0%) completed the interview. There was good inter-rater reliability in associate investigator categorization of resident responses as either self-focused or other-focused (kappa coefficient 0.85). Thirteen of 50 residents (26.0%) expressed self-focus versus three of 54 (5.4%) residents expressed other-focus experienced professionalism remedial actions (p<0.01). This association held in a logistic regression model controlling for measured confounders (p=0.02).

Conclusion

Self-focused responses to the question “Why is Medicine important to you?” correlated with professionalism remedial actions during residency.

Causes and characteristics of medical student referrals to a professional behaviour board

OBJECTIVES

To describe the nature of unprofessional behaviour displayed by medical students, as well as the characteristics of students referred to the professional behaviour board.

METHODS

A descriptive mixed methods approach was taken, in which qualitative data on unprofessional behaviour, as well as quantitative data on the demographics of referred students were collected during the study period between June 1, 2009 and January 1, 2014. In order to compare the referred students with the total student population, data on gender, nationality and phase in the curriculum of the total student population, collected from the student administration desk, were also used.

RESULTS

In the study period, a total of 107 referrals were reported, concerning 93 different students (3% of the total student population). Sixty-five of the 107 referrals (61%) concerned male students. Thirty referrals (28%) concerned non-Dutch students. Most referrals (71%) occurred during clinical rotations. The referrals were equally distributed over three professional behaviour domains: dealing with oneself, dealing with others, and dealing with tasks/work. 'Withdrawn behaviour' was reported 17 times, 'insufficient Dutch language proficiency' 14 times, 'impertinent emails' 9 times and 'placing privacy-sensitive photos on the internet' 3 times.

CONCLUSIONS

Although only a minority of students are referred to a professional behaviour board, this study shows that student characteristics such as gender and nationality may correlate to a higher incidence of unprofessional behaviour. Further explanatory and exploratory research is needed to unravel this relationship, and to study the influence of curriculum reforms on these relationships, respectively.