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Perspective: The Education Community Must Develop Best Practices Informed by Evidence-Based Research to Remediate Lapses of Professionalism

Papadakis, Maxine A. MD; Paauw, Douglas S. MD; Hafferty, Frederic W. PhD; Shapiro, Jo MD; Byyny, Richard L. MDfor the Alpha Omega Alpha Honor Medical Society Think Tank

doi: 10.1097/ACM.0b013e318271bc0b

In July 2011, the Alpha Omega Alpha Honor Medical Society sponsored a think tank of experts in the field of medical professionalism to focus on interventions and remediation strategies for those—medical students, residents, faculty, and practicing physicians—who demonstrate lapses in professional performance, particularly if the lapses are repeated. Several participants have produced scholarly work on the assessment of professionalism. However, assessment has a limited purpose unless it leads to improvements at both the organizational and individual levels. The field of professionalism has matured enough to recognize that one of the contemporary issues within the self-regulation framework is the task of remediation. Yet there is a paucity of evidence to inform best practices to help those who have lapses. Ultimately, the most effective response to an individual’s lapse in professionalism may not be simply to gather knowledge about remedial practices but also to understand organizational responses to the information about such practices already possessed by the institution.

The authors report the think tank participants’ recommendations on (1) how to use existing data on professionalism remediation and (2) what new evidence is needed to advance approaches to remediation of professional performance. Participants also recommended that the education community can focus on interventions and remediation by (1) performing studies about improving medical professionalism when lapses occur, (2) identifying best evidence-based remediation practices, (3) widely disseminating those practices, and (4) moving over time from a best-practices approach to remediation (which does not yet exist) to a best-evidence model.

Dr. Papadakis is professor of medicine, Department of Medicine, University of California, San Francisco, and San Francisco Veterans Association Medical Center, and associate dean of students, School of Medicine, University of California, San Francisco, San Francisco, California.

Dr. Paauw is professor of medicine, Department of Medicine, and Rathmann Family Foundation Endowed Chair for Patient-Centered Clinical Education, University of Washington School of Medicine, Seattle, Washington.

Dr. Hafferty is professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota.

Dr. Shapiro is associate professor of otology and laryngology, Harvard Medical School, and director, Center for Professionalism and Peer Support, Brigham and Women’s Hospital, Boston, Massachusetts.

Dr. Byyny is executive director, AΩA Honor Medical Society, Menlo Park, California.

Correspondence should be addressed to Dr. Papadakis, University of California, San Francisco, 513 Parnassus Ave., S-245, San Francisco, CA 94143-0454; telephone: (415) 476-1216; fax: (415) 502-1320; e-mail:

Professionalism is on everyone’s radar. The topic has received much attention over the last two decades from medical educators, licensing and specialty boards, accrediting organizations, and the public. Scholarly work has skyrocketed, and journals have devoted entire issues to the theme of professionalism.1,2 The work is broad and has included the development of professionalism charters, curricula, assessment strategies, and accreditation criteria by the Liaison Committee on Medical Education (LCME).3–10 However, there is a paucity of evidence to inform best practices to help those who have lapses in this fundamental domain of medical practice.11,12

In July 2011, the Alpha Omega Alpha (AΩA) Honor Medical Society sponsored a think tank that brought together experts in the field of professionalism to focus on interventions and remediation strategies for those who exhibit lapses, particularly if they happen repeatedly, in professionalism. (The names of these experts are listed at the end of this Perspective.) The think tank participants engaged in a broad and extensive discussion of professionalism and unprofessional, or disruptive, behavior. In this Perspective, we provide a context for the discussions and recommendations that occurred during the think tank meeting and summarize those discussions and recommendations.

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The practice of medicine is based on core professional beliefs and values. Many organizations, including the AΩA Honor Medical Society, have worked to define medical professionalism, codify basic professional values, support faculty development and scholarly work, and recognize individuals and organizations with exemplary professional behavior.3,13–17 That body of work, together with the inherent responsibility for self-regulation, provides a scholarly foundation for medical professionalism. Fundamental to this foundation is that persons entering the profession will accept the value climate of medical professionalism as well as have the aptitude and commitment to behave professionally. The ability to identify this aptitude at admission to medical school is promising,18,19 but work still needs to be done, given that lapses are a part of learning and that learners require education or even remediation before becoming full professionals. The academic community must now create a knowledge base and define best practices to support its efforts to forestall lapses in professionalism and to effectively remediate such lapses when they occur. This imperative is already implicit in regulation. For example, LCME Medical Students Standard 31-A states, “A medical education program must ensure that its learning environment promotes the development of explicit and appropriate professional attributes in its medical students (i.e., attitudes, behaviors, and identity).”10

The field of professionalism has matured enough to recognize that one of the contemporary issues within the self-regulation framework is the task of remediation. In medicine, profession-led regulation and individual self-regulation are important obligations for the trust of the patient, society, and the profession.20 Our profession must lead in remediating professionalism lapses or risk abdicating this responsibility to others. In fact, failure to adequately self-regulate appears to be a failing of our profession.21 This may largely reflect a failure of self-perception. Individuals who lack personal insight cannot be expected to effectively self-reflect, regulate their behavior, or improve on their performance. There was general agreement amongst the participants that despite the recognition that impeccable professional behavior is the foundation on which the trust of our patients and society rests, we generally do not have the knowledge, skills, and methodologies to address unprofessional behavior when we encounter it. Faculty have identified a sense of powerlessness in identifying their own lapses in professionalism as the single greatest barrier to teaching professionalism.22

Students arrive in medical school with well-formed and disparate identities that will influence professional identity formation. Recommendations from the reviewers of the fifth edition of the Medical College Admissions Test23 include both asking applicants to reflect on experiences that demonstrate personal characteristics and also developing standardized letters that ask recommenders to assess behaviors that demonstrate applicants’ personal characteristics. Further, premedical students’ professionalism values must enter in the discussion of lapses in professionalism, and the multiple mini-interview is an important assessment tool for ability in this domain.18,19 During medical school and residency, professional identity develops, and this “professionalization” evolves to incorporate the profession’s values and behaviors.

However, the professionalization process is not automatic or easy. Even though most students come to medical school motivated to do the best for their patients, they are all too soon exposed to the hidden curriculum, cynicism, and the realities of the delivery of health care—potent forces that serve to erode the professionalization that has occurred during training despite countervailing curricula in professionalism and inspiring role models.24–26

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Overview of Participants’ Discussion

The definition of professionalism and methodologies to assess it are well enough established,5–8,27–29 so these topics were not the major focus of the think tank discussion. The participants agreed, though, that in order to measure outcomes, some ongoing, reliable, and valid method of assessment is necessary to measure the necessity for action and the outcome of an intervention. For this reason, they concluded that discussions of remediation must include discussions about assessment. The participants applauded the evolution, while appreciating the difficulty, of the development of curricula on professionalism that are authentically imbedded throughout training, and endorsed these curricula as essential. The think tank discussion also included concerns about premedical professional values and development.

The think tank participants recognized that along with teaching professionalism, unprofessional behavior needs to be explicitly addressed. Current interventions or remediation programs for lapses in professionalism in medical schools, residency programs, and clinical sites vary, and there are no recognized best practices. It was the consensus of the participants that training programs should adopt internally consistent approaches to identify and remediate lapses in professionalism. Standardized categorization and reporting of episodes of unprofessional conduct leading to a more uniform approach to remediation would promote understanding of the extent and definition of the characteristics of the problem and allow for more efficient use of limited resources. Managing interventions to maintain uniform standards across training institutions would be even more valuable and would promote research and the development of national best practices.

The think tank participants proposed a list of essential research topics with the hope of guiding funding agencies to issue focused requests for proposals or otherwise support scholarship in professionalism. These topics fell into two groups: (1) how to most effectively use existing data on professionalism and experiences with remediation, and (2) how to generate new evidence to guide interventions for those who have displayed lapses in professionalism.

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Consensus Recommendations

How to most effectively use existing data on professionalism and experiences with remediation

  1. Gather existing practices on interventions and remediation that are used for medical students, residents, faculty, and practicing physicians and sponsor a conference on medical professionalism. The goal of the conference would be to determine best practices for the remediation of unprofessional behavior based on expert opinion while awaiting evidence-based scholarship.
  2. Determine best practices for identifying students, residents, faculty, and practicing physicians who are “at risk” for lapses in professionalism.
  3. Evaluate existing practices on remediation via formal research to demonstrate effectiveness.
  4. From nonmedical frameworks, export existing experience with cognitive behavioral therapy, motivational interviewing, and feedback intervention to the discussion of how best to remediate lapses in professionalism in medical students, residents, faculty, and practicing physicians. What is unknown is whether the behavioral interventions described in that literature will apply to the remediation of the groups listed above.
  5. Use existing programs that address unprofessional behavior as a springboard for the proposed conference on best practices. There are a few organizations doing important work in the field of addressing lapses in professionalism, and while that experience is being gained, data on outcomes remain sparse. Sullivan and Arnold30 offer an approach to principles of remediation that is applicable to undergraduate, postgraduate, and practicing physicians. Hickson and colleagues31,32 at Vanderbilt University Medical Center have done pioneering work in remediation and have contributed a valuable method of categorizing lapses in professionalism while linking interventions to that categorization. Another exemplar program is that of the Center for Professionalism and Peer Support at the Brigham and Women’s Hospital,33,34 modeled, in part, on the Vanderbilt protocol (see Box 1).
Box 1

Box 1

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New evidence that is needed

  1. Define the demographics, ethnographics, and epidemiology of lapses in professional behavior and interactions with systems issues for context.
  • What is the prevalence of unprofessional behavior in a cohort of physicians or students? Are the behaviors isolated or part of a pattern? Are there distinct domains of unprofessional behavior that cluster? How does this change over the course of medical education and practice?
  • How often are lapses of professionalism caused by “organic” causes (substance abuse, psychiatric disease) or aggravated by systems issues or other etiologies?
  1. Identify the contexts and situations that most commonly bring forth professional or unprofessional behavior.
  2. Seek a theoretical and psychological understanding of professionalism. Postulating a theory of professionalism can begin to unify existing research in the field and help identify gaps in that understanding as well as testable questions. These questions might include the following:
  • How does professional identity formation occur? What is its natural history?
  • What are the intrinsic factors influencing the individual’s behavior? What are the extrinsic factors?
  • How/why does unprofessional behavior or dysfunctionality develop? Is there a typical natural history to the development of lapses in professional behavior, with discrete stages that are potentially amenable to remediation?
  • What is the process of good identity formation, and where does departure from that take place?
  • What are the systems or institutional factors that can be used for intervention using the model of appreciative inquiry?
  1. Identify the factors that create interprofessional dysfunction and lapses of professionalism within teams. Describe the elements of training that exacerbate, or alleviate, these factors.
  2. Consider the organizational-level perspective on why organizations behave as they do around issues of individual members’ lapses in professionalism. Ultimately, the problem of lapses in professionalism may not be simply one of lack of knowledge about remedial practices or informational exchange but also of how organizations respond to information already possessed by the group. There are reasons for institutional patterns of attention and inattention, and organizations often act (or not) based on unrecognized forces. Some practices may be so entrenched that whatever the new alternatives, the organization will resist. On the other hand, the lack of new information ensures that any challenge to traditional ways of thinking and doing is limited in its ability to catalyze change.
  3. Develop feasible outcome measures to determine valid and effective methods of remediation.
  • Link remediation outcomes to assessment by others in the training environment or workplace.
  • Link remediation outcomes to patient outcomes.
  • Use licensing boards and specialty board databases.
  1. Explore predictors such as the “conscientiousness index” that identify those at risk for lapses in professionalism35 and whether these predictors can be developed for trainees and physicians in practice.
  2. Carry out prospective studies of interventions for lapses in professionalism.
  • What behaviors are amenable to change?
  • Are there different interventions for different behaviors? Does removal from exposure to repetitive unprofessional behavior enhance professionalism?
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Summing Up

The collective goal of the think tank participants was to better understand how to identify individuals who are demonstrating lapses in professionalism or who have not achieved competency in professionalism, and to find ways for those individuals to change their behavior, in order, ultimately, to help patients. This behavioral change will likely require personal accountability as well as an understanding of the organizational context in which the lapses occur. Assessment has a limited purpose unless it leads to improvement. We and the other members of the think tank believe it is now time to focus on interventions and remediation and call for

  • authentic studies into how to improve medical professionalism when lapses occur,
  • identification of best evidence-based practices, and
  • widespread dissemination of those practices.

The problem of remediation has enough gravity that we hope it will warrant the attention of funding agencies, whose support can provide answers to this continued vexing challenge for medical educators, trainees, those who deliver health care, and patients. The challenge is also to move from a best-practices approach to remediation (which we still do not have) to a best-evidence model of remediation.

Acknowledgments: The authors wish to thank Judy Yee of the AΩA Honor Medical Society for her invaluable assistance in supporting the conference reported in this article.

Funding/Support: The project described in this article was funded by the AΩA Honor Medical Society.

Other disclosures: None.

Ethical approval: Not applicable.

Participants in the Alpha Omega Alpha Honor Medical Society Think Tank: Richard L. Byyny, MD; Malcolm Cox, MD; Richard L. Cruess, MD; Sylvia R. Cruess, MD; Shiphra Ginsburg, MD; Frederic W. Hafferty, PhD; Audiey C. Kao, MD, PhD; Peter J. Katsufrakis, MD; Doug S. Paauw, MD; Maxine A. Papadakis, MD; Stephen C. Schoenbaum, MD; Jo Shapiro, MD; Henry M. Sondheimer, MD; David T. Stern, MD, PhD; and Steven A. Wartman, MD, PhD.

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