Preventing and Managing Unprofessionalism in Medical School Faculties

Abstract

Professionalism is a required competency for medical students, residents, practicing physicians, and academic faculty. Faculty members must adhere to codes of conduct or risk discipline. The authors describe issues of unprofessionalism that culminate in allegations of faculty misconduct or filing of grievances in academic medicine and outline strategies for early intervention and prevention. The authors, vice and associate deans and executive director of the office of faculty affairs at a large U.S. medical school, have handled many allegations of unprofessional conduct over the past decade. They present case examples based on behaviors such as lack of respect, inappropriate language and behavior, failure to cooperate with members of the health care team, and sexual harassment/discrimination. They discuss factors complicating evaluation of these behaviors, including variable definitions of respect, different cultural norms, and false allegations. The authors make recommendations for prevention and intervention, including early identification, performance management, education about sexual harassment, and referrals to professional coaches, anger management classes, and faculty–staff assistance programs.

Professionalism is a required competency for medical students, residents, and practicing physicians.^1–11 Its importance was highlighted in an entire issue of Academic Medicine.¹² Medical schools have policies, such as our school’s Faculty Code of Conduct,¹³ that delineate the requirements for professionally acceptable behavior; oversight of these policies is usually placed with the institution’s office of faculty affairs (sometimes called the office of academic affairs or administrative affairs).¹⁴ These offices are responsible for a range of issues, from academic advancement to grievance proceedings.¹⁵ We are the vice dean, associate dean, and executive director of the office of faculty affairs at a large U.S. medical school. Over the past decade, we have handled many allegations of unprofessional conduct by faculty—allegations filed by faculty members, staff members, students, and academic leaders. The number of allegations has been increasing: in 2009–2010, we conducted 2 investigations; in 2012–2013, we conducted 11.

Faculty misconduct cases and grievance proceedings can be stressful and unpleasant, whether one is the accuser, the accused, or the investigator.¹⁶ Because of this stress and also the time required to investigate allegations, offices of faculty affairs should develop strategies to mitigate or prevent unprofessional behaviors that may culminate in allegations of misconduct. In this article, we describe our prevention and early intervention strategies. We intend to provide guidance to faculty members so that they don’t engage in unprofessional behavior and understand the penalties if they do, to department chairs who are on the front lines of professionalism issues, and to deans’ offices of faculty affairs.

When we investigate allegations of unprofessionalism, we partner with the university’s counsel and also interview the accuser and the accused. We try, whenever possible, to resolve the issue informally. If that is not possible or if we identify a potential violation of the Faculty Code of Conduct, we refer the allegation to the vice provost for academic affairs. The vice provost then appoints a faculty committee to formally investigate and recommend sanctions and/or discipline. The scope of sanctions and discipline includes written censure, salary reduction, demotion, suspension, denial or curtailment of emeritus status, and dismissal. Our staged process, which begins with a preliminary inquiry and is followed by a comprehensive review, is similar to the process at most colleges and universities.¹⁷

We present examples below of allegations of unprofessionalism at our medical school during the past 10 years. These have included such behaviors as lack of respect, use of profanity, noncooperation with the team, sexual harassment, and discrimination. We have aggregated and modified the details to maintain confidentiality. Table 1 summarizes the types of allegations to which we have responded, as well as the strategies we have used to prevent and intervene in such behaviors.

Table 1: Description of Types of Unprofessional Behavior Addressed by an Office of Faculty Affairs at a Large U.S. Medical School, With Prevention and Intervention Strategies

Unprofessional Behaviors: Case Examples

Lack of respect

Faculty members are valued most of all for their scientific contributions and clinical expertise, so abrasive personalities are not usually a deterrent to success. Similarly, the academic freedom to debate and critique requires a certain allowance for brusqueness. Such interpersonal styles, however, can cross the boundary into behavior that violates an institution’s conduct policies. Our medical school’s Faculty Code of Conduct explicitly expects faculty members to respect their students, trainees, and colleagues and to not exploit, harass, or discriminate against them.¹³

In one case, faculty member “A” publicly criticized faculty member “B”’s research, opining that the research was badly done, biased, and unethical. “B” then filed allegations of libel. Although the principles of academic freedom allow faculty members to criticize others’ research, they also stipulate that criticism be respectful and offered with appropriate restraint.¹⁸ During our preliminary investigation, “A,” justifying the conduct, asked, “Can’t I say something is terrible if it is?” In reviewing the Faculty Code of Conduct with this faculty member, it became evident that “A” had not understood that the behavior in this case fell outside the boundaries of academic freedom and violated the code because of its public nature, the disdainful tone, and the unproven allegation of being unethical. “A” quickly understood that in the future, “A” needed to avoid such types of public statements that attack the character, rather than the ideas of a person. We ultimately referred the case to the vice provost for determination of appropriate sanctions and discipline.

Inappropriate language and behavior

Faculty members, like all humans, sometimes get angry or frustrated. In the workplace, expressing such emotions through inappropriate language or behavior can culminate in allegations of disrespect or hostile environment. Faculty members have been accused, for example, of throwing surgical instruments and screaming at staff about their perceived incompetence. Because clinical care is involved, these allegations of disruptive behavior are typically initially investigated in accordance with medical staff policies.¹⁹ If the behavior also violates academic policies, the issue may subsequently be referred to the office of faculty affairs. We have found that faculty members may not sense the discord between their conduct and the recommended rules of engagement, or not know that such conduct can be penalized. They sometimes acknowledge having a bad temper, but believe their outbursts justified. In these cases, we encourage those involved to resolve the issues informally by apologizing and modifying their behavior. If the bad behavior recurs, the matter is formally investigated, which usually leads to sanctions.

In another example, a researcher angrily cursed at a maintenance crew that had interrupted a complex experiment when they entered the lab to repair equipment. A crew member filed an allegation of inappropriate behavior. At first, the researcher justified the behavior on the basis of the concern that the experiment was compromised, but after reviewing the Faculty Code of Conduct with the faculty affairs office and learning about the penalties associated with inappropriate behavior, the researcher apologized to the maintenance crew and agreed to diligently avoid future outbursts.

Sexual harassment and discrimination

Sexual harassment and gender discrimination happen in academic health centers.^20,21 Whenever complaints of such unprofessional behavior are received, the institution’s Title IX officer should be promptly consulted. We have investigated several allegations of sexual harassment and discrimination, including overt and unwanted sexual advances. For example, a senior faculty member tried to kiss and fondle a junior faculty member, who clearly conveyed displeasure and lack of reciprocation. After our preliminary investigation, we referred the case to the vice provost’s office, which recommended academic sanctions and training in sexual harassment prevention including definitions and reporting requirements.

Complications in Evaluating Allegations of Unprofessionalism

Unclear standards for professional behavior

How can one assess unprofessional behavior in the absence of strict standards or clear definitions of such terms as “adequate respect” or “supportive environment”? In one case example, a graduate student had put in long hours and done extra work, yet felt unappreciated. When, despite all the efforts and commitment, the faculty member insisted that the student ask for permission to leave early for a doctor’s appointment, the student had had enough and filed a complaint. In the investigation, leaders in the faculty affairs office uncovered a fraught situation: The graduate student was hypersensitive to feeling unappreciated, and the faculty member was unaware that the student felt that way. To address this lack of communication, the faculty affairs office suggested that the faculty member and student meet, along with a third party, to clarify expectations and to encourage the graduate student to report accomplishments and the faculty member to express appreciation, as appropriate.

Varying cultural norms

Cultural differences may complicate all types of communications, including the mentoring process.²² They can also lead to allegations of faculty misconduct. In one example, a faculty member, encouraged by the department chair, distributed information about the university’s faculty–staff assistance program, which included mental health services, by placing a brochure on every lab bench. One lab member, a postdoctoral fellow who held culturally based, negative beliefs about mental illness, interpreted the placement of the brochure as an accusation of mental illness and filed a complaint of harassment. The faculty affairs office addressed the fellow’s misperceptions, clarified the faculty member’s intent, and no further action was necessary.

In another case example, a senior faculty member who had trained abroad told lab members that taking family leave demonstrated a lack of commitment to a professional career and that those who took leave would not get positive references. The senior faculty member also expected junior lab members to do personal tasks, such as parking his car. In response to a junior faculty member’s complaint, the faculty affairs office educated the senior faculty member about family leave rights and the norms of behavior on our campus.

The increasingly multicultural, diverse environment in which we work poses risks of misinterpreting people’s words and actions. Cultural expectations may differ regarding communication, work ethic, and work–life balance. Multicultural awareness programs, efforts to clarify professional expectations, and training programs to promote open communication are useful tools to prevent cultural misunderstandings or de-escalate interpersonal conflict.

False allegations

Occasionally, a false allegation is filed by a complainant who exhibits psychological problems. In one case, Professor “C” accused Professor “D” of fraud and publication of falsified data, a serious violation of the Faculty Code of Conduct. During the investigation, the faculty affairs office learned that Professor “C” had made similar accusations many years earlier that had all been deemed false. The department chair reported that Professor “C”’s behavior and appearance had recently begun to deteriorate, changes that had also occurred before the earlier false accusations. The chair had already referred Professor “C” to the physician well-being committee and the faculty–staff assistance program.

In another case, a postdoctoral fellow who accused a faculty member of falsifying data submitted voluminous, but difficult to interpret, supplemental materials along with the allegation of misconduct. The complainant called the office of faculty affairs every day, often rambling incoherently. Ultimately, the investigation concluded that the allegations were unsubstantiated.

When a complainant’s psychopathology may be at the root of allegations of faculty misconduct, we believe it is imperative to consult with mental health experts. Many institutions have faculty well-being committees and faculty–staff assistance programs. It is also important to recognize the impact of false accusations on the accused. Investigations, although confidential, are quite stressful.¹⁷

Strategies to Prevent and Intervene in Unprofessional Behaviors

When we determine that faculty members have behaved unprofessionally, we use the same strategies as with medicals students: early intervention, counseling, and attempts at remediation.²³ We recommend that supervisors address inappropriate language and behavior at the earliest opportunity, review institutional policies and guidelines, use professional coaches, and refer to faculty–staff assistance programs. Sometimes we require faculty members to take anger management classes. Although we do not have definitive outcome data, faculty members have told us that these classes have motivated them to change their behavior and avoid such classes in the future.

Many institutions try to proactively prevent sexual harassment and discrimination, using tools such as educational programs that supervising faculty members must regularly complete. In addition to periodic training, we support the recommendation made by Best et al²⁰ and Recupero et al²¹: that it is imperative to respond effectively to inappropriate behavior, which includes reporting and investigating all complaints of sexual harassment. Our goal is to swiftly address the underlying behavior in order to protect the complainant from continued harassment, to mediate when appropriate with both parties, and to assist supervisors, including academic leaders, in handling the complaint. We are also required to comply with the federal law codified in Title IX of the Civil Rights Act.

We have also handled complaints of a hostile work environment based on scheduling issues. Some faculty members have asked that early morning and early evening meetings be eliminated, as they are especially challenging for junior faculty with young children. Some women on the faculty consider these meetings evidence of discrimination by their male supervisors. When we hear these complaints, we encourage the women to talk to their supervisors, bring these issues to the supervisors’ attention, and request a change in the times of meetings.

In addition to formal complaints about discrimination, we frequently receive informal inquiries from female faculty who believe that their salary is low because of their gender. In response, we review the salaries of comparable positions within the division or department. It is difficult to fully address these concerns because compensation is partially based on standard salary tables and partially on negotiation with the chair. We urge chairs and managers to develop, implement, and communicate the policies and guidelines they use to set salaries.

We have sometimes found that chairs and division chiefs shy away from having difficult conversations and giving corrective feedback regarding unprofessional behavior. They often postpone handling a conflict and wait for a “better” time to address the issue. This avoidance style of conflict management may preserve a relationship in the moment of conflict, but it ultimately leads to more difficult situations.²⁴

There have been cases in which supervisors have been concerned about faculty members’ inadequate performance, but have failed to address it with a performance management plan based on a fear of grievances. Performance management plans include specific performance expectations, provide feedback, and include periodic appraisals of progress. When the supervisors are forced, finally, to speak to the faculty members, the faculty members are surprised; after all, they have never received any negative feedback. In fact, they may have regularly advanced academically. At that point, a supervisor’s admission of discomfort helps far less than if a performance management plan had been put in place when its necessity became apparent.

In general, physicians, other health care providers, and research scientists are not trained in business practices and may feel uncomfortable managing situations involving poor performance. It is important to inform faculty members and supervisors that offices of faculty affairs and human resources are institutional resources that can be used to prepare for uncomfortable or challenging situations. Most institutions have policies that outline how to notify faculty members about performance issues and how to identify the appropriate resources. For example, our medical school has progressive discipline policies for staff and faculty.²⁵

We have found it common for supervisors to hope that faculty problems will spontaneously resolve before formal action is needed. However, spontaneous resolution is extremely unusual. Moreover, if the issues go unspoken, underperforming faculty members are unlikely to even be aware of their problematic behavior or its impact on others, further reducing the likelihood of spontaneous improvement. Avoidance also does disservice to the institution; if a conflict escalates to the point of non-reappointment or termination, the faculty member could challenge that notice by claiming that the institution had not followed its own policies and procedures regarding notice and counseling.

Discussion

To our knowledge, this is the first article to describe the types of unprofessional behaviors that are referred to offices of faculty affairs in medical schools and to delineate strategies for prevention and early intervention. We have described a range of situations that have culminated in grievances against faculty members. These complaints range from misunderstandings to serious allegations. We have also described prevention strategies such as early identification, performance management plans, education about and dissemination of policies, and encouraging the use of professional coaches, faculty–staff assistance programs, anger management classes, clear communication, and awareness of cultural differences in the workplace.

Although less than 1% of faculty members are investigated each year, complaints about faculty misconduct are increasing. We have seen a fivefold increase in investigations undertaken by our office in the last three years, and the Title IX officer on our campus has also reported an increase in complaints. We believe that these figures may be underestimates. Not all allegations of misconduct result in investigations by our office; some are handled within departments or through informal meetings. It is also unclear whether our educational programs have resulted in greater awareness of unprofessional behavior, which may increase the number of complaints without an actual corresponding increase in faculty misconduct. Still, we anticipate even more types of unprofessional behavior to emerge. The Federation of Medical State Boards, for example, has issued standards for the appropriate use of electronic and social media.²⁶

Although our composite cases represent a range of complaints, we use the same systematic approach for all investigations. We attempt informal mediation, facilitate communication, and encourage the use of formal apologies. During the course of the investigations, we consult with our university counsel, the Office of Human Resources, and our Title IX officer. We also meet with our university counsel each month to understand the broader legal context. We believe that both complainants and respondents consider our process fair and equitable.

Although investigating allegations of unprofessionalism will undoubtedly continue to be a responsibility of offices of faculty affairs, we believe that education, prevention, and intervention, as well as a systematic process for handling complaints, can minimize the number of allegations as well as the stress and time involved in investigations.

Acknowledgments: The authors wish to acknowledge the assistance of the University of California, San Francisco Office of Legal Affairs in reviewing this manuscript and in assisting with our cases.