Arora, Vineet M.; Wayne, Diane B.; Anderson, R. Andy; Didwania, Aashish; Farnan, Jeanne M.; Reddy, Shalini T.; Humphrey, Holly J.
Medical educators and the public are increasingly concerned about threats to physician professionalism.1,2 Because professionalism is one of the Accreditation Council of Graduate Medical Education core competencies,3 several programs have incorporated professionalism teaching in residency training curricula.4–6 Residency may inadvertently promote increased participation in unprofessional behaviors due to the “hidden curriculum,” or actions of faculty members or others observed by the resident in the learning environment. This is especially true of internship which is often characterized by fatigue, burnout, heavy workload, and lack of time to appropriately reflect on the intense clinical experience.7
To date, few data exist on which unprofessional behaviors may be promoted during internship. In a prior study, incoming interns in three residency programs reported participating in behaviors they recognize as unprofessional.8 Moreover, interns who reported participating in an unprofessional behavior were less likely to perceive this behavior as unprofessional. By understanding the behaviors that internship promotes, program directors can better monitor residents for these behaviors and design programs to address these behaviors. The aim of this study was to ascertain changes in perception of and participation in unprofessional behaviors among internal medicine interns during internship at three Chicago residency programs. We hypothesized that internship would promote participation in unprofessional behaviors and that unprofessional behaviors would be perceived as increasingly appropriate.
On the basis of a prior survey of third-year medical students9 and input from five residents and five faculty members, a 28-item anonymous survey was adapted to assess participation in and perception of unprofessional behaviors in residency. Because terminology reflects how interns perceive or discuss behaviors, certain items use vernacular unique to residency or refer to behaviors which may not appear unprofessional to attendings. For example, during survey development, “blocking” admissions was identified by residents as unprofessional. Likewise, although attendings may sign out by phone, interns viewed this as unprofessional because face-to-face sign-out is the norm. Items were reviewed by site faculty for institutional relevance and face validity and piloted with internal medicine junior residents at one site. Domains (See Table 1) included fraud, disrespect, misrepresentation, on-call etiquette, shift work mentality, behavior related to students, disregard for education, hospital policy, and unprofessional dress. Behaviors ranged from egregious (relating to categories of fraud, disrespect, or misrepresentation) to controversial (attending a pharma-sponsored dinner or behaviors related to shift work mentality/duty hours).10
Participants reported whether or not they had ever participated in a particular behavior and rated their perceptions of these behaviors as “unprofessional” on a Likert-type scale ranging from 1 (unprofessional) to 5 (professional). Surveys were administered at the beginning by paper at one site and electronically (Survey Monkey, Portland, Oregon) at two other sites between July and September in 2007. Follow-up surveys were administered electronically with up to three weekly electronic reminders to nonresponders at all sites between July and September 2008 (Vovici Survey Software, Dulles, Virginia, and Survey Monkey, Portland, Oregon). Subjects for this study included interns who completed a full year of internship.
To facilitate truthful reporting, an introductory paragraph emphasized survey anonymity and the importance of truthful responses. Because preliminary interns may have differed from categorical interns in their behaviors or perceptions of professionalism, interns were asked to identify if they were categorical or preliminary. This study was exempt from review by the institutional review boards of the University of Chicago and Northwestern University.
Data from paper surveys were entered by a trained research assistant and merged with data from electronic surveys using Microsoft Excel with numeric codes denoting site and baseline versus postinternship. Descriptive statistics were used to summarize participation in unprofessional behaviors. Multivariate logistic regression, controlling for site and intern type (categorical versus preliminary), was used to assess the association between postperiod and participation in unprofessional behaviors. Site-adjusted ANOVA was used to assess the association between postperiod on perceptions of unprofessional behaviors. To account for multiple comparisons, statistical significance was defined as two-sided P = .003 after Bonferroni correction.
There were 112 internal medicine interns who completed one year of internship in the three training programs. Two preliminary interns who completed nine-month internships and four medicine-pediatrics interns were excluded. One hundred five (93%) completed the presurvey and 99 (88%) completed the postsurvey. Response rates for Site 3 (81% pre, 70% post) were lower than for Site 1 (100% pre, 98% post) and Site 2 (100% pre and post) (P < .05). Preliminary interns composed 17%, 17%, and 57% of site complement (no specific order). Of 30 eligible preliminary interns at baseline, response rates were 100% at baseline and 90% at follow-up. Response rates by site for preliminary interns ranged from 83% to 100%, closely mirroring overall site response rates.
As noted in prior work, rates of participation in egregious behaviors related to misrepresentation, fraud, or disrespect were not trivial.8 For example, 19% reported making fun of patients (19/102 pre and 19/99 post) and 14% (pre) and 11% (post) reported falsification of patient records. However, there was no change in the rates of participation in egregious behaviors related to misrepresentation and fraud or disrespect.
In site-adjusted multivariate analyses, there was a statistically significant increase in participation in unprofessional behaviors related primarily to on-call etiquette. After internship, interns were more likely to report blocking an admission (19/102 pre and 19/99 post), misrepresenting a test as urgent to expedite care (40% pre versus 60% post; P = .003), and signing out over the phone (20% 20/102 vs. 42% 41/98, P < .001), Although not statistically significant, interns reported increased participation in disparaging the ER for missing findings later discovered on the floor (27% 27/101 per vs. 45% 45/99 post, P = .005). Interestingly, participation in behaviors related to medical students decreased. For example, fewer interns reported asking students to consent patients for minor procedures without supervision (36% 37/102 versus 18% 18/99, P = .001) or to discuss information beyond their level of knowledge with patients (18% 19/103 versus 5% 5/99, P = .007). Of note, there were no site differences in changes in participation rates of unprofessional behaviors.
After controlling for site and for participation in the behavior, there was no change in perceived level of appropriateness for any of the unprofessional behaviors. Nearly all behaviors were rated as either “somewhat unprofessional” or “unprofessional.” Two behaviors, staying past shift limit to complete work and answering family member questions during cross-cover, were deemed “neutral” (mean perception score ≈ 3) before and after internship. The only behavior that interns perceived as more professional after internship was attending a pharmaceutical-sponsored dinner or social event, although this change was not statistically significant (2.88 versus 3.36, P = .04).
Recent research has reported resident perceptions of unprofessional behaviors in the learning environment of teaching hospitals.11 In this multicenter study with high response rates, we found that participation in egregious unprofessional behavior did not increase during internship, and participation in unprofessional behaviors related to on-call etiquette appeared to worsen during internship. With the exception of attending pharmaceutical-sponsored dinners, unprofessional behaviors were not perceived as increasingly professional.
It is important to consider why rates of participation in on-call unprofessional behaviors selectively increased. First, interns work extended duty shifts, which are characterized by fatigue which can lead to emotional liability and burnout and contribute to lapses in professional behaviors.12 Intern workload is also busiest during this time,13 which may result in hostility towards toward those who admit patients to interns, namely the emergency department or a primary care physician. With increasingly short lengths of stay and difficulties ordering tests in a timely fashion in many teaching hospitals, interns likely feel pressured to misrepresent tests as urgent to ensure timely care. This is an example of a “workaround,” or pursuing an alternative path that leads to the desired outcome, but it is wasteful. It is also possible that interns may work with residents or attendings who actually promote participation in unprofessional behaviors.
Our results have implications for future efforts to improve professionalism in residency. First, interventions to monitor and promote professionalism during on-call duty hours periods should be undertaken. Examples include educating interns on the appropriate role of emergency department and primary care physicians in triaging patients or debriefing with interns about challenging situations they have encountered while on-call. Adopting system solutions that improve the ability of residents to be more effective on-call may also be helpful. These solutions may include redesigning test ordering to ensure that tests are completed in a timely fashion so that interns would not misrepresent tests as urgent. Likewise, ensuring appropriate workload and adequate rest during on-call periods may prevent lapses in on-call etiquette. Last, residency programs should emphasize that staying past shift limits and attending pharmaceutical-sponsored social events are not condoned.
Interestingly, participation in egregious unprofessional behavior (i.e., related to fraud, disrespect, misrepresentation) did not change during internship. Because incoming interns reported a concerning level of participation in these behaviors, earlier identification and remediation in medical school is warranted.14 Periodic assessment of the medical school learning environment, as required by the Liaison Committee on Medical Education, can ensure that student exposure to unprofessional behavior is minimized.15
Interestingly, participation in at least one unprofessional behavior related to medical students decreased after internship. This increase may be explained by higher baseline rates reflecting that interns answering the item on the basis of their own experiences as students. As interns progressed through internship, they may be more sensitive to medical student needs because of their proximity in training. To fully understand these findings, more investigation of student mistreatment may be needed.
There are several limitations to this study, the most substantial of which is that interns may have inaccurately reported their participation or perceptions related to unprofessional behavior either because of fear of being identified, recall bias, or the conflict in admitting to indiscretions. Moreover, we did not examine actual participation in unprofessional behavior or quantify frequency of behaviors. Because the survey was anonymous, we cannot detect changes over time for specific interns. We asked interns if they had “ever participated” in the behavior and assumed any changes were due to internship. Because this survey and items were initially developed for medical students, certain behaviors may be less relevant to residents despite pilot testing. While survey items reflected how residents may refer to certain unprofessional behaviors, confusion about interpretation of certain items may have occurred. For example, a resident may refuse accepting a patient to his or her service if it is an appropriate patient care decision. This is in contrast to “blocking” in which residents do not accept a patient to avoid additional work. The study was also conducted in three Chicago medicine residencies, limiting generalizability to training in different disciplines in other parts of the country. A future national study examining unprofessional behaviors among trainees in other specialties would be helpful.
In a multiinstitution longitudinal survey of medicine interns, perceptions of and participation in most unprofessional behaviors did not increase during internship. After internship, internal medicine trainees reported increased participation in unprofessional behaviors related to on-call etiquette. Interventions to promote professionalism during internship should focus on on-call behaviors. Further study is needed on the effect of targeted interventions on the professionalism of medical trainees. On the basis of these findings, and with support from the American Board of Internal Medicine Foundation, we are designing interventions for residents and faculty to improve and promote professional on-call etiquette.
The authors wish to thank Mike McGinty and Meryl Prochaska of the University of Chicago for technical assistance.
This study was funded by the University of Chicago Pritzker School of Medicine, Northwestern University Feinberg School of Medicine, and NorthShore University HealthSystem.
Dr. Arora had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the statistical analysis. Dr. Arora and Dr. Wayne reported receiving honoraria from the American Board of Internal Medicine. Drs. Arora, Wayne, Anderson, Didwania, and Humphrey are members of the Association of Program Directors of Internal Medicine. Dr. Humphrey reported receiving honoraria from the American Board of Internal Medicine and having been president of the Association of Program Directors of Internal Medicine. We also report receiving the Putting the Charter Into Practice grant from the ABIM Foundation.
This study was determined to be exempt from review by the institutional review boards of the University of Chicago and Northwestern University.
The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.
The abstract of an earlier version of this article was presented at the 2009 Society of General Internal Medicine Meeting.
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