Kanter, Steven L. MD
Over the last few decades, much has been written about professionalism in medicine—what it is, how to recognize it, how to measure it. There is good potential for this work to lead, one day, to even better methods than we currently use to address unprofessional conduct.
But faculty affairs deans, residency program directors, and deans of students can't wait for that day. They simply do not have the luxury to delay action until there are better answers. These committed and caring individuals work on the front lines of medical schools and teaching hospitals where, at any moment, they may be called on to pass judgment about what constitutes professional versus unprofessional conduct, whether or not it is appropriate to initiate a preliminary inquiry or a full-fledged investigation, and what should be done to deal with inappropriate behavior. At times, they must administer disciplinary actions ranging from a minor reprimand to relief of duty or even dismissal. Their decisions must be fair and just, and are subject to scrutiny by deans, lawyers, and other institutional officials.
Fortunately, most faculty, residents, and students behave professionally, and unprofessional conduct is rare. But when it does occur, it is best dealt with expeditiously.
Through the years, I have spoken with many deans and directors about their approaches to dealing with unprofessional conduct by faculty, residents, or students. I have heard about a variety of approaches and how they were effectively (or not so effectively) applied to very challenging situations. As I listened to colleagues' stories, I could sense their passion for the values that make medicine a profession as well as their concern about the destructive consequences of unchecked unprofessional conduct. At the same time, I could discern the wisdom that they brought to each situation, the creativity they used to craft imaginative solutions to the most challenging problems, and the expert manner in which they devised a plan, both ethical and pragmatic, to make things work.
Some of these individuals explored the assumptions and inferences implicit in their approaches to unprofessional conduct. Some went so far as to develop a set of operating principles to guide their efforts. Almost all relied to some degree on intuition, a grandmother's aphorism or two, and a bit of what they had learned in kindergarten.
I, too, have drawn lessons from my own experience over the course of two decades of dealing with various forms of misconduct. In fact, I have developed an explicit, conscious philosophic approach that guides my actions and enables me to assess them. This approach can be described by six conceptual continua, each of which depicts a tension between two anchoring goals. The six continua are rehabilitation–punishment, restoration–separation, local venue–remote venue, informal process–formal process, civility–hostility, and dignity–expediency.
In a given situation, these continua help me focus efforts on rehabilitating an individual who may have had a lapse in judgment, and restoring that individual to his or her prior level of professional function or prior standing as a student or resident. Punishment and separation from the institution, while sometimes necessary, are more costly to both individuals and institutions.
These continua bring to consciousness the value of preserving dignity and civility, consideration and respect for the perspectives of all involved, and recognition of applicable social and cultural norms. This is important, especially because the job stress and time pressure of a dean or director can precipitate feelings of hostility toward an individual who takes up a seemingly disproportionate amount of time; these feelings can lead a dean or director to seek expedient remedies. A conscious focus on these continua can provide a valuable set of checks and balances for this natural tendency.
An informal resolution to many situations involving misconduct can lead to a quicker and better outcome than a formal proceeding (unless a formal proceeding is required), as does managing the situation “locally” within a department or division rather than “remotely” at a school or university level, farther from the site of the incident.
Hickson et al. writing in the November 2007 issue of this journal1 (which was devoted entirely to the topic of professionalism) provide a rationale for the importance of identifying, measuring, and addressing unprofessional behaviors. The authors offer a four-stage model to guide interventions in cases of disruptive behavior, with the four stages spread along a spectrum that I described above as the rehabilitation – punishment continuum.
In this issue of the journal, Lucey and Souba, in an article titled “The Problem with the Problem of Professionalism,”2 discuss the advantages of conceptualizing professionalism as a complex, adaptive problem rather than a simple or technical one. They also suggest that approaches used to understand medical errors can be used to understand and deal with unprofessional conduct. Furthermore, their “Assumption 3” is another example of the tension characterized by the rehabilitation – punishment continuum described above.
I agree with Lucey and Souba that professionalism is better characterized as a complex, rather than simple, problem and that characterizing it as such will lead to better ways to resolve situations involving breaches of professional conduct. And the model proposed by Hickson et al. is a very useful guide to implementing the rehabilitation-punishment continuum.
The time is ripe to extend the discussion even further and to build a consensus in the academic medicine community for a sound philosophy of dealing with unprofessional conduct. I propose the six continua presented above as a starting point. A set of principles that underpin our approach to dealing with unprofessional conduct will provide faculty and student affairs deans and residency program directors with a valuable touchstone to guide action and assess performance. Shared discussions and deliberations, along with new evidence from research on professionalism, can lead, over time, to enrichments and refinements of this philosophic approach. And such a philosophy – one that is rehabilitative, restorative, civil, and dignified – reflects the raison d'être of all those who work at medical schools and teaching hospitals every day: to educate and to heal.
Steven L.Kanter, MD