Recent studies have identified concerning patterns of unprofessional behavior by resident physicians, including falsifying reports of duty hours and dishonestly answering Accreditation Council for Graduate Medical Education (ACGME) survey questions. Media reports reflect the results of these studies, with identification of “padding” publications and cheating on examinations by both medical students and residents.1 , 2 Despite this publicity, the prevalence and impact of these behaviors are not well described.
Definitions of the term “professionalism” vary in the published literature. A 2002 charter published by the American Board of Internal Medicine, the American College of Physicians–American Society of Internal Medicine, and the European Federation of Internal Medicine3 defined “professionalism” as “the basis of medicine’s contract with society.” The charter focused on three fundamental principles: (1) the primacy of patient welfare, (2) patient autonomy, and (3) social justice. While the charter provides physicians with a foundation of “should” and “should-not” behaviors, it offers only a relatively nebulous concept of “unprofessional” and dishonest behaviors. Further, the charter fails to propose methods for identifying or remediating such actions.
Although many published studies review professionalism training, and many examine specific unprofessional behaviors, we could find no published studies to date that provide a review and analysis of the various studies that cover this topic. We sought to produce a descriptive assessment of unprofessional behavior in medical training as well as to quantify the prevalence of specific behaviors by reviewing published studies of unprofessional behaviors in U.S. medical trainees, in order to help educators identify, remediate, and prevent these behaviors in the future.
We performed a literature review looking for all published studies on unprofessional behavior among U.S. medical school students (including foreign medical graduates applying for U.S. residency programs) or resident physicians. The primary author performed a search to identify all articles published in English and indexed in PubMed between January 1980 and May 2014. We selected the search start date (1980) to identify studies relevant to modern medical education. Search keywords included medical student, resident, and/or doctor, combined with cheating, falsification, unprofessional, dishonest, plagiarism, misrepresentation, and fraud.
To determine which articles to include in the review, the primary author assessed the titles and abstracts of the 1,254 citations the initial search identified. We retrieved relevant articles and submitted them to a thorough examination to determine candidacy. We included additional references by reviewing items in the works-cited lists of search-identified abstracts and articles. We included only studies that presented original and quantifiable data describing unprofessional, dishonest, or fraudulent behaviors among U.S. medical students or resident physicians. Final inclusion was at the discretion of author interpretation. The primary author determined individual study inclusion or exclusion. We excluded studies on impairment due to alcohol and substance abuse from this review, as this area is already well described in the literature.4 , 5
We determined the prevalence rates for given behaviors, for descriptive purposes, by calculating the sum of quantifiable events from individual articles and then dividing the sum by the aggregate population in the reference sets. For studies evaluating the misrepresentation of publication listings on applications, we generated the rates reported below by dividing the collective number of applicants with misrepresented or fraudulent citations by the total number of collective applicants across all relevant studies. If misrepresented or fraudulent citations were not clearly defined, we reported the number of unverifiable publications in its place.
The initial reference set included a total of 1,254 citations. After reviewing abstracts, we determined that a total of 51 publications met our criteria for inclusion in the study.1 , 2 , 6–54 These studies featured disparate methods of data reporting and examined various behaviors among medical students or residents. To simplify analysis and reporting, we grouped the results into categories based on the primary populations of the study (i.e., medical students or residents) and the behaviors studied (e.g., cheating, plagiarism).
Seven cross-sectional studies surveying medical students6–12 and two retrospective reviews of examination results52 , 53 assessed cheating on tests among medical students. Of the seven survey studies, four were single-institution surveys and the other two included respondents from multiple institutions. The authors of the earliest reported study in our review (1980) found that, of the 400+ medical students they studied, 58% admitted to cheating on tests during medical school.6 Another early report (1982) reveals the results of a survey of medical school deans representing 106 medical schools: Deans representing 76% of the schools reported that they had formal allegations of cheating against students in the four years leading up to the survey.12 Results of a 1983 survey of 271 medical students at one medical school showed that 17% of students reported cheating in the first two years, and 27% reported cheating on tests in the third or fourth years of school.7 In a set of surveys administered to more than 300 students at a single medical school from 1988 to 1990, 23% admitted to cheating,8 and in a 1994 survey of 174 medical students at a single institution, 19% to 22% of students reported having knowledge either of individuals copying from one another or of a “crib sheet” during a course examination.9 In a 1996 survey of nearly 4,000 medical students, 5% admitted to cheating in the first two years of medical school, but 39% reported that they witnessed cheating at least once over the four-year course of their undergraduate medical education.10 In a 2009 survey of over 2,500 U.S. medical students, 2% reported copying from or allowing another student to copy during an examination.11
Finally, in two large reviews (published in 2009 and 2014) of the Comprehensive Osteopathic Medical Licensing Examination USA Level 2-Physical Examination, 0.2% of examinees received a failure for fabricating examination SOAP (i.e., subjective, objective, assessment, plan) notes.52 , 53
Misrepresentation of publications.
Twenty-three single-institution studies investigated the publication history of applicants to U.S. residency programs (Table 1).13–34,44 The total number, combining the results of these 23 studies, of applicants whose applications contained misrepresented or fraudulent material is 667 (9% of 7,797 applicants).
We identified only one, single-institution retrospective study of medical student plagiarism, but this study included nearly 5,000 applications to residency programs; the authors reported that over 5% of medical student applications contained plagiarized material.35
Falsification of documentation.
Our search uncovered a single report of students falsely reporting information about patient encounters.36 The authors conducted a single-institution retrospective review of 207 videos of medical student encounters with three standardized patients and found that 61% of notes documented physical exam findings of maneuvers that, according to the video, medical students did not perform.36
Other dishonest or unprofessional behaviors.
We included three additional studies that evaluated dishonest and other unprofessional behaviors among U.S. medical students.8 , 11 , 37 A range of 13% to 24% of graduating students surveyed between 1988 and 1990 at one institution admitted to dishonest behaviors during clinical clerkships, including recording tasks in the medical record that they did not actually perform or lying about ordering tests that they had not ordered.8 A 2009 survey of more than 2,500 U.S. medical students revealed various self-reported unprofessional behaviors; for example, 43% admitted reporting a result as normal when it had not been assessed in the physical exam.11 Further, more than a quarter of these survey respondents admitted to more than one unprofessional behavior.11 Finally, a survey of 57 psychiatry clerkship coordinators found that at most institutions (70%), one to three medical students exhibited unprofessional behavior warranting intervention on an annual basis.37
Two single-institution studies38 , 39 and two investigational journalism reports1 , 2 evaluated cheating behavior among resident physicians in the United States. A survey of 57 general surgery residents published in 2010 indicated that 5% to 21% had engaged in, or would consider engaging in, cheating behavior regarding the use of memorized questions for the American Board of Surgery In-Training Examination (ABSITE).38 A similar survey study, published in 2013, reported that 22% of general surgery residents admitted to using, or would consider using, memorized questions from previous tests to prepare for the ABSITE, and 30% to 31% knew of others who had engaged in this behavior.39 A Cable News Network investigative report (2012) indicated that the use of “recalls,” or “remembrances” (exam questions that have been recollected and transcribed for future examinees) from the American Board of Radiology test was widespread among radiology residents.1 An additional report from popular media identified 139 internal medicine board certification candidates who were sanctioned in 2010 for exchanging copyrighted board questions.2
Misrepresentation of publications.
Six studies in our review—all reports of retrospective studies at fellowship programs—examined the misrepresentation of publications among residents (Table 1).26,40–43,45 Combining the results as reported in all six studies, a total of 104 applications (representing 14%) contained misrepresented, unverifiable, or fraudulent material from a total of 757 resident applications for fellowships.
We found only one publication—an editorial—that reported plagiarism among resident physicians.46 According to this editorial, three personal statements in 26 applications (12%) to a geriatric medicine fellowship in one year contained plagiarized material from a single Web site.46
Falsification of documentation.
Four cross-sectional studies—three national surveys47 , 48 , 54 and one institutional survey49—on falsification of duty hours met our inclusion criteria. A 2011–2012 national survey of over 6,000 residents across a wide range of specialties found that 43% of residents falsely reported duty hours; surgeons were the most common violators (62% reporting duty hours falsely), followed by residents in internal medicine (59%) and pediatrics (48%).47 Four other specialties reported falsifying duty hours at rates greater than 40%.47 Another national survey from 2012 found that 60% of neurosurgery residents underreported duty hours,48 and a study of 720 family medicine residents found that 18% admitted to underreporting duty hours.54 Finally, a 2006 study of 175 residents in varying specialties at one institution revealed that 48% of residents admitted to underreporting duty hours.49
A single cross-sectional study reported on false responses to the ACGME resident and fellow survey.55 Specifically, 14% of nearly 1,000 general surgery residents admitted to not answering the ACGME resident and fellow survey truthfully.55
In an another cross-sectional survey study of 571 residents regarding their first postgraduate year, 45% reported directly observing other residents falsifying clinical and other records.50
Other dishonest or unprofessional behaviors.
Two cross-sectional surveys50 , 51—the first of residents and the second of program directors—reported on other unprofessional or dishonest behaviors among medical residents in the United States. In a survey regarding their first postgraduate year, 74% of 571 residents reported observing the mistreatment of patients by colleagues, and 73% reported witnessing colleagues working in an impaired condition.50 In a survey of nearly 300 internal medicine program directors, 94% reported having “problem” residents, and 15% of these problem residents exhibited “unacceptable moral or ethical behaviors” (not further elaborated).51
This literature review evaluates studies, published since 1980, on unprofessional and dishonest behavior among U.S. medical school students (including foreign medical graduates applying for U.S. residency programs) or resident physicians. We identified a total of 51 publications containing quantifiable data on unprofessional behaviors. These studies featured disparate methods of data reporting and evaluated various behaviors among medical students or residents. As a whole, the representative data on the subject in the literature are poor; most reports provided data derived from single-institution studies or survey instruments.
Overall, the data suggest that plagiarism, cheating on examinations, listing fraudulent publications, and other unprofessional behaviors have occurred at a steady and concerning rate across three decades. On average, unprofessional behaviors were reported in 5% to 15% of the student and resident populations studied. Other behaviors, such as inaccurately reporting maneuvers during a medical examination or falsifying duty hours, appear to be even more common (40%–50% of students and residents).
Some risk factors for unprofessional behavior seemed similar across studies. Foreign medical graduates had significantly higher rates of publication misrepresentation than U.S. medical graduates.15 , 16 , 18 , 29 , 32 , 44 Interestingly, other risk factors for falsifying applications included a higher number of reported publications,16 , 18 , 32 higher reported board scores,13 reported additional advanced degrees,18 and older age.16 , 18 , 44 More specifically, a higher number of reported publications and more reported first-author publications were also risk factors for misrepresentation in studies evaluating fellowship application publication listings.40 , 45 Plagiarism similarly was more common among foreign medical graduates than U.S. students. Contrary to citation misrepresentation, plagiarism was associated with low board scores, lack of research experience and publications, and having undergone a previous residency or fellowship.35
Risk factors for other unprofessional behaviors were not uniform. Falsifying duty hours was more common among surgeons.47 , 48 Psychosocial factors, most notably professional stress and burnout, appear to be risk factors for unprofessional behavior. In a survey of medical students regarding unprofessional behaviors, each behavior occurred more frequently in students who had higher self-reported burnout.11 In fact, professional distress was the only factor on multivariate analysis that was predictive of students having engaged in more than one unprofessional act.11 An additional analysis demonstrated that such behaviors were also more common in individuals with poor mental health as determined by validated mental health instruments.56 The role of burnout in unprofessional resident behavior is not yet established, although it likely plays a role given that burnout is common in this population.57 Finally, male students and residents were found to be more likely to cheat10 and misrepresent their publications.32
Among the studies we reviewed, we found insufficient evidence to suggest that unprofessional behaviors have changed since 1980. Regrettably, many of these studies involve small subgroups of trainees at individual institutions or in individual specialties, limiting generalizability and making comparisons exceedingly difficult. In addition, certain behaviors have only recently been reported because of the short time course in which they have been documented (e.g., duty hours falsification, ACGME survey dishonesty). Table 2 displays the representative studies and the relationship between specific unprofessional behaviors and the decade from which the data were obtained to illustrate the difficulty in demonstrating a temporal pattern.
Relevance, context, consequences, and remediation
The relevance and impact of unprofessional behaviors among medical students and residents have not been well defined. Undoubtedly, both the public and medical professionals would agree that many behaviors, such as criminal activity or cheating on board examinations, are egregious and warrant disciplinary action or remediation. However, other behaviors such as duty hours falsification are not as easy to judge. For instance, surveys have indicated that many program directors and residents disagree with duty hours regulations.54 , 58–63 Disapproval of these duty hours regulations may serve as justification for many individuals either to overlook underreporting or to be complicit in false reporting.64 In one recent survey of duty hours falsification, negative perceptions of duty hours were strongly correlated to increased false reporting.47
The definition of “unprofessional behavior” is by no means clear. While most medical educators would agree that cheating, plagiarism, and lying about credentials all clearly constitute unprofessional behaviors that are directly contradictory to the professional principles of physicians, other behaviors are more ambiguous. Further evidence for the discordant or lacking definition of “unprofessional behavior” comes from the results of surveys of medical students and residents which suggest that trainees’ perceptions of the severity of the behaviors may be more forgiving or even in conflict with those of educators.65 In addition, students disagree even with one another as to what actually represents unprofessional or unethical behavior.39 , 66 Furthermore, perceptions of professionalism may be context specific,67 and the components considered most important may vary according to level of training.68 Finally, the underlying reasons or motivations for engaging in such behaviors have not been defined as of yet, but may be related to factors such as burnout, fatigue, and the competitive nature of medical education.
The expanding literature on physician unprofessionalism may be based on a concern about what happens when unprofessional behaviors are learned and go uncorrected during physicians’ formal education. Unprofessional behavior during training may lead to unprofessional behavior when physicians graduate into unsupervised practice. Some evidence for this correlation comes from studies demonstrating that individuals who are disciplined as physicians were more likely to display irresponsible or unprofessional behavior in medical school compared with controls who were not disciplined.69–71 These studies suggest that unprofessional behaviors occurring early in medical education may be predictive of future unacceptable behavior.
This study has a number of important limitations. First, the results are derived from studies with varied methodology and data outcomes measures. Most data are derived either from a multicenter survey or even from a single-institution sample. Notably, many of the studies included in this analysis have significant biases, and many use sampling instruments with inherent limitations. In addition, we did not catalog the reasons for excluding articles during the literature search process and therefore cannot offer descriptive assessments of journal articles excluded. Finally, inclusion and exclusion were determined by the primary author, not by committee consensus, which may introduce bias into the results.
Understanding the prevalence, risk factors, relevance, and consequences of unprofessional behaviors among future physicians in the United States should be a priority. To allow for the scientific study of these behaviors, the medical education community should, first, develop a unified definition of “unprofessional” behaviors and then work to identify these behaviors and differentiate them from other misbehavior or inappropriate behavior. This goal may be best served by an organized committee of trainees and educators from a broad range of specialties who are involved in undergraduate and graduate medical education. The effort to define unprofessional behaviors must also address generational differences among trainees and faculty; multiple generations may hold diverse views of unprofessional behaviors and what consequences, deterrents, and remediation strategies are suitable. Once the community comes to a consensus on the definition of “unprofessional behavior,” medical educators should develop and validate standardized instruments to study these behaviors. Such tools would allow the community to quantify and monitor the prevalence and consequences of these behaviors during undergraduate and graduate medical education and then, in turn, to develop remediation strategies that fit the types of behaviors and their seriousness. A recent study noted significant variation in remediation strategies with different strengths and weaknesses.72 Further research into remediation protocols may eventually provide evidence-based and standardized strategies. Interventions to educate medical students and residents about professionalism and to prevent unprofessional behaviors could then be evaluated. Given that the nature and sequelae of such behaviors are poorly defined, scientifically evaluating their causes and impact must be a priority.
We reviewed 51 articles examining unprofessional or dishonest behavior among medical trainees in the United States. The results of this analysis indicate that despite the importance of the topic, relatively little evidence-based information on it exists. “Unprofessional behavior” lacks a unified definition. The data currently available on the prevalence of unprofessional behavior in medical students and residents are limited, and where data are available, they derive from instruments with significant limitations that sample small population subgroups. The sampling instruments themselves lack standardization and validation. Unprofessional behaviors are common and seem to occur in various demographic groups within the medical trainee population. The prevalence of such behaviors does not seem to change over time, but evolving policies may cause changes in what is considered unprofessional. The relationship between unprofessional behaviors in training and future disciplinary action is poorly understood; however, some evidence indicates that these behaviors may predict future unprofessional behavior. Going forward, acknowledgment and careful study of the incidence, motivations, and consequences of these behaviors are crucial. “Unprofessional behavior” should be clearly defined, and instruments for its study should be created and validated so that behaviors may be evaluated scientifically. A cross-specialty committee of physicians with expertise in undergraduate and graduate medical education may be necessary to achieve these goals.
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