Medical schools have the desire and responsibility to produce “good doctors”—that is, ones who are competent, having not only the requisite knowledge and skill, but also the expected attitudes and behaviors such as caring, compassion, and putting the needs of the patient ahead of their own. These constitute the elements required of the profession for the formation of the bond of trust essential to the patient–doctor relationship.1–3 Thoughtful groups have defined professionalism,4 struggled with its assessment,5–9 and sought correlates that would accurately predict it.10–13 Yet despite considerable efforts to select for and instill professionalism, unprofessional behaviors persist, resulting in poor patient care, compromised quality and safety, nursing turnover and burnout, poor role modeling, and mistreatment of trainees.14
Medical school deans have taken this problem seriously and responded with policies, safe reporting procedures, responsible committees, mandated trainee education, faculty development programs, counseling of disruptive or impaired physicians, reward and recognition for exemplary behavior, and so on.15–21 And yet at one institution a longitudinal study of these measures failed to show improvement in an important indicator of professional behavior: student mistreatment.22 As noted by another school with a comprehensive “road map” to improve the culture of professionalism, the faculty proved to be the greatest challenge because they viewed the problem as an admissions or medical education issue.21 If the unprofessional behavior of faculty goes undetected or unreported, it becomes ingrained in the culture via the “hidden curriculum”23–30 and is then perpetuated in the next generation of physicians. As described by Lucey and Souba,31 the problem of professionalism is a complex learning problem, one that requires a new approach. Students are capable of identifying unprofessional behaviors provided there is a reporting mechanism safe from retaliation.6,32–35 They also fulfill Stern’s8 suggestion that an effective assessment of professionalism uses multiple observers in realistic situations over time.
In this longitudinal observational study we sought to determine the effect of feedback from the dean on faculty whose behavior was described as least professional by graduating medical students.
For the classes of 2007 through 2012, we asked senior medical students at the Southern Illinois University School of Medicine (SIUSOM) to complete an anonymous paper survey a few weeks before each graduation. To complete the survey, they read the definition of professionalism described by the American Board of Internal Medicine and the relevant section from the school’s code of conduct; submitted the names of the “most professional” and “least professional” faculty members in each department based on their personal experiences or observations (not hearsay from others); gave the reason for naming faculty as “least professional” and/or a suggestion for improving unprofessional behavior; and were asked to work on their own without discussing their choices with others. During the study period there were no other school or department-wide professionalism initiatives being undertaken.
One faculty member per department per year with the greatest number of “most professional” nominations received a letter from the dean, with a copy to their chairman, thanking them for their exemplary behavior. Only those faculty named by the greatest number of students as exhibiting unprofessional behavior (also one per department per year) were asked to meet with the dean, or in rare cases with their departmental chair because of personnel factors, to discuss the student observations. During this meeting with the dean, the only topic of discussion was the specific student comments. These faculty were given a typed, redacted copy of comments and asked for their reaction. Reactions were varied and included surprise, denial, defensiveness, criticism of the study’s validity and, most commonly, embarrassment and a desire to improve. The dean acknowledged that comments may be more than one year old and behavior could have changed or been influenced by events occurring at the time, etc. Student perceptions and faculty intent were discussed, followed by a mutual expectation that the unprofessional behavior observed by students would improve in subsequent surveys. Our purpose was to constructively criticize rather than punish. No record of the conversation was kept.
The nine departments reviewed, and average number of total faculty per department, were as follows: year one basic science (35), year two basic science (36), family medicine (38), internal medicine (55), neurology (18), obstetrics–gynecology (14), pediatrics (36), psychiatry (18), and surgery (54, subspecialties included). Faculty considered the most professional in each department were those who received the greatest number of nominations, provided they received at least 15% of the votes cast. The most unprofessional faculty member in each department was defined as the person nominated most often, provided the person was named by greater than 5% of the class. No attempt was made to weight the data according to the extent of contact students might have had with individual faculty.
To facilitate a blinded review of survey data, we transferred responses to a spreadsheet after assigning a number specific for the year, the individual faculty, and that person’s department. One of us (J.K.D.) redacted student comments to remove any information that could easily identify an individual. Two of us (N.K.R. and B.W.) analyzed the comments describing unprofessional behavior using grounded theory method36 supported by Atlas.ti, version 7.0.86, a qualitative software package (Atlas.ti Scientific Software Development, GmbH, Berlin, Germany). We met twice to code one year of comments together, so we could come to agreement on how we would code, using an initial set of codes derived from the literature on unprofessionalism.14,27,32,35 New codes were created when the existing codes were insufficiently descriptive of the comments. We then coded each of the remaining five years of comments independently. We met three more times to review coding to ensure that we agreed. Each comment was categorized such that its character was fully described. We used two categories of codes to describe each student comment. Demographic codes identified employee (by an anonymous employee number), department, and year the comment occurred. Each comment was also characterized by as many as six descriptive codes, such as rude/demeaning; poor teaching style; disrespecting students/residents. Students made a total of 874 comments describing unprofessional behavior of 177 faculty members. These comments were described by 1,749 uses of 78 descriptive codes.
Each comment was also coded with an individual faculty identifier (a code created by the dean’s office to maintain faculty anonymity), a study year, and a department code, also generated by the dean’s office. Faculty who served as clerkship directors had a special code assigned in those years. This allowed us to track individual faculty members over time, to describe various departments, and to track the number of comments made each year. It also allowed us to discern the environment referred to in the comments. The dean’s office, using data external to the study, made comparisons between faculty identified as most and least professional on a variety of quality and demographic indicators. Chi-square analysis was used to determine statistical significance of any differences.
The institutional review board of SIUSOM approved this study with analysis of the data occurring in 2012.
We distributed surveys to a total of 416 graduating medical students during the course of the six-year study period, and 385 surveys were completed for an overall response rate of 92.5%. The response rate ranged from 81% to 100% for any given year. For comparison, 95.8% of graduating seniors completed the Association of American Medical Colleges (AAMC) Graduation Questionnaire during the study period. Table 1 shows data for the most professional faculty compared with the most unprofessional faculty by chi-square analysis. Though not specifically instructed to do so, some students chose to select either no one or more than one person as the most or least professional in a department.
An unexpected finding was the greater number of most unprofessional faculty who left this institution compared with those identified as most professional faculty. During the study period, nine faculty voluntarily resigned within two years of being named the least professional in their department. All were clinicians. Six of these individuals were on the faculty during the first year of the study and accounted for 33% of the total names submitted as being unprofessional in that year. Of the seven most unprofessional faculty identified in the 2007 and 2008 surveys, who were counseled by the dean and remained on the faculty in 2011 and 2012, their combined number of all nominations for unprofessional behavior fell from 126 to 9. These seven faculty accounted for 30% of all the least professional nominations in 2007–2008 but only 4.3% of nominations in 2011–2012. After the meeting with the dean, none of the most unprofessional faculty received this designation in subsequent surveys.
We calculated the yearly number of faculty nominated in either the most or least professional categories divided by the number of survey respondents that year. The results are shown in Figure 1. During the six-year study period, the number of most professional faculty averaged 8.4 per year or about 1 per department, while the number of least professional faculty declined from 3.8 to 1.4 per year. The total number of least professional nominations fell steadily from 208 to 92 at the conclusion of the study.
Profile of unprofessional characteristics overall
Shown in Table 2 are the types of unprofessional behaviors that students commented on regardless of setting—they occurred both in classroom settings and in clinical settings. They are present in approximately though not precisely equal proportion in all departments; thus, they can be said to represent the kinds of behaviors students will attend to in all learning situations. Four of the top eight occurring unprofessional behaviors were associated with teaching activities (disrespecting students/residents; poor teaching style; ignoring teaching responsibilities; and biased evaluation). In contrast, faculty nominated as most professional were likely to have been recognized for their teaching activities by humanism or teacher-of-the-year awards. The other four top occurring behaviors pointed to difficult interactional styles (being rude/demeaning; being arrogant/condescending, lacking humility; jokes, insensitive comments; being overly familiar). In this context, “poor teaching style” encompassed both an attitude toward teaching medical students as well as the perception of competence as a lecturer/teacher.
Other frequently occurring unprofessional behaviors were specific only to clinical faculty—for example, the code “disres pecting patients/families,” which occur red 125 times, and “inappropriate manage ment of patient interactions,” which students noted 42 times.
Clerkship directors as a special case
It should be pointed out that, of approximately 300 faculty, the greatest number were never or rarely cited as being either the most or the least professional in their department. This could be explained by the varying degrees of exposure a given student had to a faculty member as well as the construction of the survey instrument asking only for identification of the most and least professional. Furthermore, it was very rare to have students in any given class mention a single faculty member as both the most and the least professional. The exception occurred when a faculty member was a clerkship director, charged with grade assignment and giving performance feedback to the student. Clerkship directors tended to be at increased likelihood for being identified as least professional. Thirteen faculty members were identified as least professional when serving as a clerkship director. Of these, seven were not mentioned as least professional when they did not serve as a clerkship director. Of the remaining six, five had substantially fewer comments about their professionalism when not serving as a clerkship director. One was mentioned substantially more times when not a clerkship director.
Over the six-year study, students contri buted a total of 874 unique comments about faculty professionalism. Of these, the 13 faculty mentioned above received 130 during their service as clerkship direc tors—approximately 15%. The most fre quent category of complaint was biased evaluation, with 26 comments coded as such; however, 2 faculty members received 21 of those comments. The next most frequently occurring was disrespecting students/residents, with 21 comments coded. Being rude/demeaning was coded 20 times, inappropriate evaluation 12 times, and poor teaching style 11 times. Perhaps predictably, all these categories of unprofessionalism are related to teaching. Interestingly, though, 15 comments were coded disrespecting patients/families, which represents 12% of all of the mentions of this form of disrespect. This suggests that clerkship directors may be under enhanced scrutiny in their dealings with patients and families. Once this was recognized, we informed affected clerkship directors so that they would have a context in which to consider the feedback they received and make them aware of areas of student sensitivity.
The profession of medicine is based on a covenant of trust between patient and doctor, and that covenant may be highly dependent on readily observable physician attitudes and behaviors. Moreover, the attitudes and behaviors of teachers create and maintain the culture of their institution and perhaps the profession. We undertook this study of medical students’ perceptions of faculty behavior to assess the impact of feedback to individual faculty whose behavior was judged unprofessional by graduating students at a single medical school. The dean or another authority was chosen to give feedback because he was interested, saw the work as important, was privy to sensitive information, and had the “moral authority.” Furthermore, in a report to the AAMC Counsel of Deans, involvement of the dean in response to issues of student mistreatment was seen as a critical element in schools that performed well on this aspect of the AAMC Graduation Questionnaire. It was not unexpected to find that faculty recognized for their teaching ability and humanism were identified as the most professional in their respective departments. The converse was also not a surprise; students often equate poor teaching with unprofessional behavior.29 We saw that to be especially true for basic science faculty, where comments regarding teaching style, attitude toward teaching, etc., dominated the narrative. Perhaps this was a conse quence of the more limited venue that basic science faculty occupy.
The manner in which this survey was conducted likely made it a safe environment for students as judged by the high response rate. However, a reporting system solely dependent on students is an inadequate institutional monitoring mechanism as evidenced by three faculty who were formally disciplined for unprofessional behavior during the study period but who were not commented on by students. Other limitations of this study are that it was done at a single medical school with its unique culture and that the conclusions may not extrapolate to other institutions. Response rates were good, but not all students were in a position to observe all faculty. The varied opinions of learners can contribute to inconsistency in reporting, but we attempted to mitigate this by having a minimum threshold for declaring someone the most unprofessional lest that faculty be labeled as the result of a difference of opinion with a very small number of students. Furthermore, some faculty were counseled well after their unprofessional behavior was noted, potentially lessening the impact of more timely feedback.
Students frequently cited lack of respect for patients, families, students, residents, staff, and other faculty as the least professional behavior. This aligns with the findings of other similar studies.14,24–27,29,35 A qualitative analysis of 874 comments made about 177 faculty in nine departments showed that students are especially attuned to unprofessional behavior related to teaching and to interactional style in all areas of the learning environment.
While many unprofessional behaviors were widespread and not localized to a department or specialty type, there were several instances of a behavior localized to one or a few individuals. A good example is that of a single faculty member who made a racist remark in a lecture. When that class completed the survey a few years later, one-fourth of the class identified that individual as the least professional in the department. This faculty member was counseled by the chair soon after the event, and no further reports of such remarks occurred. To us, this was dramatic evidence of the potential influence of role models and the hidden curriculum, and that feedback can improve behavior. It is essential that this feedback is individual, specific, and focused on behaviors that students have observed. Policies, generalized statements, or rules to address poor behavior will not suffice.
We were pleased to see a decline in the number of faculty singled out for their unprofessional behavior during the course of this study with no change in the number named for their exemplary behavior. Two factors may have contributed to this observation. First, the behavior of the most unprofessional faculty appeared to significantly improve when informed how they were perceived by students. Second, a disproportionate number of the most unprofessional faculty left the school within two years of their meeting with the dean. All of these separations were voluntary, and it is not known what effect meeting with the dean had on their decision. Because the results of the study were only made known to the appropriate faculty and their chairs, and because no other similar interventions were being executed at the school or department level, it is less likely that a major behavior change was occurring throughout the institution as a result of another initiative. Although this may have had a net beneficial effect on the professional culture at our school, it raises the likely possibility that these individuals will settle in a more tolerant or less aware training institution.
Further analyses of student comments, both qualitative and quantitative, will look at differences among the clinical specialties with the anticipation that unique unprofessional behaviors could be addressed during resident training. We also intend to extend this line of work to include a correlation study between nursing staff professionalism rankings of attending physicians and patient outcome data such as length of stay, readmission rate, and complications.
If we are to improve the culture within the profession of medicine, policies and practices must be implemented in all training institutions.22,37 These must include a safe reporting mechanism, direct involvement of higher administration, frequent assessment of the learning environment, a clear statement of expected behaviors and attitudes, a willingness to confront those whose behavior fails to meet these standards and provide the appropriate level of intervention, and a mechanism to reward exemplary behavior.38 It is not enough to have programs in place to detect and remediate egregious offenders alone. Continuous improvement of the culture of respect demands that we measure and reduce its variability among teachers who serve as role models. By providing feedback to those whose behavior is lacking, we can begin to answer the call issued by Leape et al39 to “do something about this invidious problem and cultivate a culture of respect.”
Acknowledgments: The authors wish to thank Nancy Wells (Office of the Dean) for transcribing student comments and assigning demographic codes, Randall Robbs, MBA, and Steven Verhulst, PhD (both from Southern Illinois University School of Medicine Center for Clinical Research), for their contribution to the statistical analysis, and the anonymous reviewers whose suggestions significantly improved the manuscript.
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