ACADEMIC EMERGENCY MEDICINE 2011; 18:S97–S103 © 2011 by the Society for Academic Emergency Medicine
Objectives: The Accreditation Council for Graduate Medical Education requires residency training programs to teach and assess professionalism in residents; however, programs may struggle to successfully remediate residents not meeting professionalism standards. To assist programs with this complex issue, a Professionalism Remediation Task Force was formed by the Council of Emergency Medicine Residency Directors (CORD-EM), which surveyed program directors (PDs) concerning their experiences. The purpose of this study is to report survey results regarding the identification and rating of unprofessional behaviors and challenges in the evaluation and remediation of professionalism.
Methods: In June 2010, the task force sent an anonymous survey via the CORD-EM listserv to PDs with active EM programs.
Results: Fifty percent (77/154) of eligible PDs responded to the survey. Most PDs rated the unprofessional behaviors of interpersonal/communication conflicts, lack of responsibility during patient care, lack of respect of coworkers, and reports of impairment as “critical”; repeated tardiness, incomplete work, poor ability to accept feedback, poor attitude, and repetitive unresponsiveness to aid colleagues were rated as “very serious”; frequent missed deadlines were “serious”; and repetitive failure to complete medical records was rated as “mildly serious.” A resident with “less serious” professionalism issues was also felt to be likely to have “serious” or “critical” issues “often” (33.8% of respondents) or “always” (6.5%). The most common methods of assessment were clinical/advisor evaluations. However, existing assessment methods were described as inadequate in identifying serious professionalism issues by 50.7% of responding PDs. Unprofessionalism was most commonly discovered by unofficial faculty complaint (54.5%). Eighty percent report that professionalism is more difficult to remediate than other core competencies. Resident ownership of the problem was reported as most critical to remediation success (84.4%). PDs perceived the greatest challenges in residency remediation to be lack of resident insight or responsibility for the problem (45.2%) and personality/behavioral issues (32.9%).
Conclusions: Identification and remediation of professionalism in EM residents is challenging. A future goal is to create a system by which PDs can use standardized pathways as a guide to identify and remediate unprofessional conduct.
Teaching and assessing professionalism in resident learners is mandated by the Accreditation Council for Graduate Medical Education (ACGME); however, programs may struggle with methods to evaluate professionalism in their learners. Professionalism in residents may be more difficult to assess than the other core competencies.1,2 This difficulty may be due to a lack of agreement among evaluators as to what defines professionalism and which attributes are most important.1–3 If a program determines that a resident has a lapse in professionalism, there are few tools available to help address the problem. Furthermore, reliable and validated methods to assess residents’ professionalism competency do not exist at this time.3
Adding to the complexity of the problem, residents who are unprofessional may not be identified by standard assessment methods.4–7 Difficulty with early identification and characterization of a professional lapse can impede the development of an appropriate remediation plan, which can subsequently affect its success.1,8 Defining successful remediation needs to be transparent for both the program and the resident, but measures of success may be difficult to determine.9 Meaningful outcome measures and evidence of long-term behavioral change may be difficult to ascertain, and programs may be left with proxies such as patient surveys, quality indicators, or employer evaluations of graduates to gauge success.10 As a result, despite investing significant time and resources to remediate unprofessional residents, training programs may question the outcome of their efforts.
Among medical students, it has been found that deficient responsibility, the inability to demonstrate self-improvement and adaptability, and weak initiative and motivation are unprofessional behaviors that predict future state medical board disciplinary actions.11 Internal medicine residents who had lower professionalism evaluations during training were also at increased risk for state licensing disciplinary actions.12 These studies underscore that the professionalism competency is a high-stakes responsibility for residency training programs. Training programs may need to dismiss unprofessional residents to prevent harm to patients to uphold the professional standards in medicine.13 Training programs may need to dismiss unprofessional residents as a means to prevent harm to patients and uphold the professional standards in medicine.
To assist residency training programs with the complex issue of professionalism remediation, the Council of Emergency Medicine Residency Directors (CORD-EM) created a Professionalism Remediation Task Force in 2009. The task force was charged with developing resources that could assist programs with remediating residents with substandard professionalism. To better comprehend the needs of programs regarding professionalism remediation, we first surveyed EM residency directors to understand their experiences and challenges with this process and to search for best practices for professionalism remediation.
Study Design and Population
This was a survey study using the CORD-EM e-mail list to target EM residency program directors (PDs). The institutional review boards of the authors’ institutions determined that the research study was exempt from full review.
Survey Content and Administration
Emergency medicine residency PDs were surveyed using a secure, anonymous, electronic survey instrument regarding their experiences with unprofessional behavior and professionalism remediation in their trainees. PDs were told that the survey would facilitate the development of resources that could assist programs with professionalism remediation. Only PDs with active programs as of June 2010 were asked to participate. Each PD could take the survey only once. The survey was distributed via the CORD-EM e-mail list in June of 2010, and all data were deidentified.
PDs were asked to rate the seriousness of a variety of unprofessional behaviors using a 1–5 Likert scale (1 = not serious at all, 2 = mildly serious, 3 = serious, 4 = very serious, and 5 = critical). Open coding was used to group responses by themes for “write-in” answers on the survey.
Simple descriptive statistics are reported.
Seventy-seven of 154 (50%) eligible EM PDs completed the survey. Two-thirds of responding programs reported having a professionalism code of conduct or similar document for their program. Eighty percent of PDs believe that professionalism is more difficult to remediate than the other core competencies.
When asked to report the yearly incidence of residents with unprofessional behavior in their program, 54.5% of PDs reported none or one resident, 35.1% reported two to three residents, 5.2% reported four to five residents, and 5.2% cited six or more residents. Unprofessional behavior was most commonly first recognized in postgraduate year (PGY) 2 residents (45.5%), followed by PGY 1 (33.8%), and PGY 3/PGY 4 residents (5.2%). Twenty-two percent stated that unprofessional behavior was identified equally throughout all postgraduate years. Sixty-eight percent of responding PDs reported that no residents had been dismissed from their programs in the past 5 years for professionalism issues, and 32.5% reported that one or two residents had. Forty-two percent reported that they were aware of a graduate within the past 5 years with substandard professionalism who continued to have professionalism issues in practice.
Table 1 reports the severity of specific behaviors as rated by PDs. When asked to identify the number of residents per year that required remediation for “serious” issues (scored as 3–5 in Table 1), 74% reported none or one resident per year, 20.8% reported two to three residents per year, 2.6% reported four to five residents per year, and 2.6% reported six or more residents per year. When questioned how often residents with a pattern of “less serious” professionalism issues (scored as 1–2 in Table 1) also had “serious” issues, 23.4% of PDs reported “rarely,” 36.4% reported “sometimes,” 33.8% reported “often,” and 6.5% reported “always.”
|Unprofessional Issue (Number of Respondents)||1, Not Serious at All||2, Mildly Serious||3, Serious||4, Very Serious||5, Critical|
|Persistently incomplete medical records (n = 76)||1 (1.3)||34 (44.7)||28 (36.8)||10 (13.2)||3 (3.9)|
|Repeatedly showing up late for conference, didactics, or shifts/rotations (n = 77)||0 (0)||12 (15.6)||21 (27.3)||28 (36.4)||16 (20.8)|
|Frequently missing deadlines: assignments, licensing, paperwork, contract completion, etc. (n = 77)||0 (0)||9 (11.7)||32 (41.6)||24 (31.2)||12 (15.6)|
|Leaving work incomplete at the end of shift, “dumping” on another resident (n = 77)||1 (1.3)||8 (10.4)||14 (18.2)||32 (41.6)||22 (28.6)|
|Interpersonal/communication conflicts with nurses, technicians, and other health care team members, EM and other faculty, or consultants/residents from other services (n = 77)||0 (0)||4 (5.2)||7 (9.1)||30 (39.0)||26 (48.6)|
|Interpersonal/communication conflicts with patients (n = 76)||1 (1.3)||3 (3.9)||4 (5.3)||29 (25.0)||49 (64.5)|
|Lack of respect of nurses and healthcare team members, EM faculty or other specialty faculty, consultants/residents from other services (n = 77)||1 (1.3)||3 (3.9)||8 (10.4)||25 (32.5)||40 (51.9)|
|Poor ability to accept performance feedback/constructive criticism (n = 77)||0 (0)||5 (6.5)||26 (33.8)||32 (41.6)||14 (18.2)|
|Poor attitude—complains on shift about work load, teaching responsibilities, reports of “lack of enthusiasm” on rotations, etc. (n = 77)||0 (0)||10 (13)||24 (31.2)||29 (37.7)||14 (18.2)|
|Repeatedly not being responsive to health care team member requests for help (n = 77)||0 (0)||9 (11.7)||17 (22.1)||28 (36.4)||23 (29.9)|
|Lack of responsibility, ownership, accountability regarding patient care (n = 77)||0 (0)||3 (3.9)||8 (10.4)||19 (24.7)||47 (61.0)|
|Reports of “impairment” or “unfit for duty”—substance abuse, emotional issues (n = 77)||2 (2.6)||2 (2.6)||0 (0)||6 (7.8)||67 (87.0)|
The methods of professionalism assessment that residency programs currently use are reported in Table 2. PDs were asked to identify all modes of evaluation used by their program and were encouraged to write in any methods used that were not listed in the survey. The number of respondents that used each method of assessment is listed in the table. In a follow-up question regarding how useful their assessment methods were in identifying serious professionalism issues in residents, 50.7% of PDs felt that their current methods were inadequate. In fact, 45.5% felt that their manner of professionalism assessment “sometimes” identified serious issues, and 5.2% reported that the methods “infrequently” did.
|Method of Assessment (N = 77)||n (%)|
|ED evaluations||76 (98.7)|
|Off-service evaluations||72 (93.5)|
|Advisor and/or evaluations with residency leadership||67 (87.0)|
|360o evaluations||52 (67.5)|
|Educational activities (Objective Structured Clinical Exam, simulations, oral boards, etc.)||38 (49.4)|
|Other (write in responses):|
(5)-Chart completion/reviews, duty hour compliance reporting, residency/hospital requirement compliance
(5)-Incident reports, staff reports, discussion with faculty
(2)-Standardized Direct Observational Assessment Tool
(1)-Behavior at residency social events
(1)-Officer evaluations on core military principles (military program)
Table 3 reports the most common means by which unprofessional behavior is brought to the PD’s attention. Respondents could write in a response if the method of discovery regarding unprofessional behavior was not listed. Of note, the professional assessment methods reported in Table 2 were infrequently the means by which resident unprofessional behavior was discovered.
|Method of Discovering Unprofessional Behavior (N = 77)||n (%)|
|“Curbside” complaint of faculty||42 (54.5)|
|“Curbside” complaint of nursing or other healthcare team member||11 (14.3)|
|Formal complaint from healthcare team (other services, nurses, clerks, technicians, etc.)||8 (10.4)|
|ED clinical evaluation||6 (7.8)|
|Critical incident||3 (3.9)|
|Off-service evaluation||3 (3.9)|
|Chief resident or other peer resident||2 (2.6)|
|Other (write in responses):||2 (2.6)|
|(1)–Interactions with program coordinator and staff|
|(1)–Databases that demonstrate compliance with clinical and nonclinical duties|
|Formal complaint from patient||0 (0)|
|Educational activities (OSCE, simulations, oral boards, etc.)||0 (0)|
Table 4 reports what PDs believe to be the most important predictors of successful remediation of unprofessional behaviors. The PDs’ perceptions of the greatest challenges and obstacles in remediating professionalism are reported in Table 5. Resident “ownership” that a problem exists was overwhelmingly reported as the greatest predictor of successful remediation, but also the greatest challenge to the process.
|Predictors of Success (Two Choices Allowed), N = 77||n (%)|
|Resident ownership that a problem exists||65 (84.4)|
|Resident conveying a genuine desire to change their behavior||23 (29.9)|
|Having a remediation plan that “fits the crime”: addresses the issue in a meaningful way and not merely viewed as punishment||19 (24.7)|
|Resident responsibility in the remediation plan||17 (22.1)|
|Consistency with the plan; “no exceptions” to missed deadlines, continued behavioral issues, and consequences||14 (18.2)|
|Other (write-in responses):||3 (3.9)|
|(1)–Underlying cause of the issue (impairment, immaturity, mental illness)|
|(1)–Knowledge by the resident that monitoring is occurring|
|(1)–Demonstrated professional behavior over time (beyond remediation)|
|Challenge/Obstacle (Required to Write in Response) N = 73||n (%)*|
|Insight/ownership/responsibility for the problem, responsiveness to feedback/criticism||33 (45.2)|
|Personality/behavioral/attitude issues||24 (32.9)|
|Resident’s desire to change and “buy in” to the remediation||7 (9.6)|
|Recidivism of unprofessional behavior, including during/after remediation||5 (6.8)|
|Defining problem and cause, defining remediation expectations and monitoring||5 (6.8)|
|Time intensive process, follow through by the program director||4 (5.5)|
|Lack of resources/tool kit||3 (4.1)|
|Clear and accurate documentation of issues, plan, consequences||3 (4.1)|
|Trust—between the residency and the resident during the process or resident regaining trust of residency||2 (2.8)|
|Delay in reporting/discovering problem/faculty not willing to confront the resident||2 (2.7)|
|Balance between remediation and disciplinary actions||1 (1.4)|
|Multiple faculty working with the same resident during remediation||1 (1.4)|
Finally, we asked PDs to write in what was the most important thing that the task force could provide to assist them with formulating professionalism remediation plans for their residents. Approximately 35% of respondents requested “best practices” of remediation plans or case vignettes. Seventeen percent of PDs wanted a “tool kit” as a resource for remediating unprofessional residents. Specific requests included clear remediation strategies, standardized agreements, and structured templates.
Early identification of medical students who demonstrate unprofessional behavior is necessary for expedient intervention.14 This is likely to be equally true for residents. If unprofessional behaviors are not identified and addressed, or are overlooked until a resident’s senior year, there is little time for effective remediation. Our survey results indicate that most unprofessional behavior was first recognized in the PGY 2 year. Marco15 opined that delayed identification of a resident with unprofessionalism is not only “unfair” to the resident, but also prevents successful remediation to effectively change behavior.
Identification of unprofessionalism requires both reporting and documentation. Our study demonstrated that unprofessional behavior was most frequently reported by “curbside” complaints from faculty or other health care team members. Lack of reporting by faculty, nursing staff, and patients is a large barrier to early identification and recognition of patterns of unprofessionalism. Fear of reprisals and confrontation are factors that lead to underreporting. In fact, one study reported that 20% of internal medicine PDs surveyed avoided the issue of problem residents out of fear of legal retribution.6
In addition, unprofessional behaviors may be overlooked or underreported in residents who excel in the other core competencies. For example, repeated tardiness to conference may be overlooked if a resident has superior performance in medical knowledge. Our study demonstrates that there are significant obstacles to reporting unprofessional behaviors. Therefore, we recommend that PDs seriously consider all notifications, regardless of formality (for example, “curbside” discussions may be just as valuable as written evaluations), in assessing the possible need for remediation.
Finally, EM PDs who completed our survey classified the seriousness of unprofessional behaviors. Our survey demonstrated that residents with less serious professionalism lapses often escalated to have more serious lapses. Thus, PDs should have a heightened awareness of residents who exhibit any unprofessional behaviors and take caution in dismissal of “minor” infractions. PDs might want to consider these results when reviewing and developing assessment methods for professionalism.
It is important to have adequate resources available in order to address professionalism appropriately. Our survey reported insufficient documentation, inadequate remediation plans, and a lack of resources as significant challenges to the remediation process. Additionally, our results demonstrated that PDs may struggle with developing a remediation plan that fits the lapse and is not viewed by the resident as mere punishment. PDs do not want the resident to view the remediation as reprimand for bad behavior, but rather hope that the resident will see it as an opportunity to change facets of his or her behavior to improve as a physician. Remediation success is measured through behavioral modification. However, whether the true lesson of what defines professionalism is embraced and incorporated into future practice by the resident may be the ultimate measure of success.2,16 The development of meaningful remediation plans is more difficult when professional lapses are subtle, repetitive, or in the category of mild to moderately severe.13,17,18
The remediation plan requires buy-in from faculty that a problem exists, along with a commitment to participate in the process. Any remediation program must be uniquely tailored to the resident’s behavior and institution, with clear documentation of the problem and an action plan that is tangible and measurable.8,18,19 Obtaining information from multiple sources, documentation of the deficiencies, and remediation with frequent assessments requires time and an unwavering focus on the part of the PD. It is the opinion of the authors that a resident’s professionalism remediation or probation plan without the endorsement of the faculty may unintentionally perpetuate the notion that a problem does not really exist, which can then undermine the integrity and morale of the program and institution.
Written responses from our survey indicate the perception that unprofessional behavior often stems from a resident’s underlying personality or character and, as a result, is less amenable to meaningful, long-term behavioral change. This may create an additional remediation challenge, as some believe that it is difficult to teach professionalism, and in a sense morality, to an adult who lacks either the insight into what behaviors are unprofessional or the genuine motivation to change. Huddle20 pointed out that while professionalism can be taught in medical training, there must be acknowledgement that physicians are not moral amateurs; professionalism is a “form of medical morality more difficult to live up to than the norms of medical expertise.”
Resident “ownership” that a problem exists was overwhelmingly cited in our survey as the most important factor in predicting successful remediation. Therefore, meeting with the resident is vital to assess the resident’s perspective on the issue, and to achieve understanding and instill a sense of responsibility, by educating the resident about the problem and its effects. A basic tenet of professional formation is predicated on a resident’s insight, self-awareness, and receptivity to feedback.21 A resident may attempt to defend behavior and minimize the severity of events. Residents with substandard performance rarely identify themselves as deficient, bringing into question the trainee’s ability to self-assess his or her performance accurately.6 Therefore, addressing resident denial early in the process is crucial.
Remediation success can be improved by assigning a mentor or advisor and providing frequent performance feedback,6,7 both of which may promote acknowledgement by the resident that a problem exists. Resident self-assessment of professionalism during the remediation process, and assumption of responsibility in the formation and execution of the remediation plan, may foster accountability.8
A program might consider a root cause analysis approach to assist in professionalism remediation. Namely, by first understanding the error or lapse, and identifying contributing factors, PDs may ultimately prevent future occurrences through resident education, addressing system issues, defining expectations, and requiring resident and system accountability.8
While there is a broad acceptance that standardized patient encounter assessments, particularly in undergraduate medical education, do correlate with future performance during residency, there is much uncertainty as to what techniques are effective for remediating unprofessional behavior.14,18 This uncertainty also exists in teaching professionalism as a core competency. Educational programs may struggle to provide meaningful outcome measures for professionalism, let alone establish evidence of long-term behavioral change when it comes to those residents who require remediation.
The ultimate goal of the task force is to create a system by which PDs can use standardized pathways as a guide to identify and remediate unprofessional conduct. Incorporating the perceptions and experiences of EM PDs will be an important first step. Developing a grading standard for a set of unprofessional behaviors could also benefit the assessment and remediation process.
One factor not addressed in this survey is the external influence of the professional standards modeled within our own institutions. We as educators need to examine ourselves and the institutions in which we work. Institutions, more than before, can challenge altruism and integrity, as medical technology, patient expectations, and commercialism in medicine are on the rise.22 Many authors point to the hidden curriculum—that of what the residents see, hear, and witness in the hospital.23 Educators can be equally culpable with respect to unprofessional conduct, yet are often protected by institutional hierarchy or a lack of willingness of leadership to act or discipline medical staff. Furthermore, disruptive conduct can be reinforced and rewarded in some microsystems.24 Recruiting positive faculty role models who possess the moral vision and character that residents can emulate is imperative to succeed.
One of the most instructive questions from the survey referenced postgraduate performance of residents who underwent professionalism remediation during their training. It revealed that over 40% of PDs were aware of a graduate with substandard professionalism who continued to have professionalism issues in practice. This implies that accurate identification, albeit through flawed and qualitative measures, is high. Formulating graduate medical education best practices for professionalism can help programs ensure that their residents achieve lifelong competency in professionalism. The ultimate challenge is to demonstrate efficacy of those standardized best practices for teaching and remediating professionalism.
Fifty percent of EM PDs responded to our survey. While a higher response rate would have ensured better validity, the purpose of the study was to obtain preliminarily background information regarding the scope and challenges with professionalism remediation in residents.25
Survey bias and recall bias could have affected the results. Additionally, the structure of our survey responses for two questions did not allow a respondent to distinguish between “zero” and “one” resident. Not distinguishing among these responses does not provide data on exactly how many residents per year in any given program have professionalism deficiencies. However, we feel that the results are still important in that 45% of programs have two or more residents per year with substandard professionalism, and 26% of programs report two or more residents per year who require professionalism remediation.
Identification and remediation of professionalism in emergency medicine residents is challenging. Our survey results found that current assessment methods for professionalism do not always reliably identify those residents with serious professional lapses. Less serious professionalism lapses often predict more serious lapses in residents. “Curbside” complaints about residents are an important indicator of unprofessionalism and should not be dismissed. The greatest predictors of remediation success are the resident’s ownership of the problem, paired with a genuine desire to change the unprofessional behavior. Program directors should seize the opportunity to intervene early and address the deficiencies of a resident who displays any lapse in professionalism. A future goal is to create a system by which program directors can use standardized pathways as a guide to identify and remediate unprofessional conduct.