Attending to professionalism lapses of undergraduate medical students is a demanding and time-consuming task for educators.1 How to manage professionalism lapses is not taught, nor does expertise come easily.2 Despite its acknowledged importance, there is no evidence indicating which behaviors should be remediated to prevent future problems, nor which behaviors are not amenable to change. Knowledge about managing professionalism lapses will provide institutions with evidence-based tools by which to make decisions about their students (i.e., whether a student should be allowed to graduate). An empirically derived model that can guide medical educators to make these decisions about professionalism lapses is required.
Teaching, modeling, and monitoring professionalism in undergraduate medical education are crucial for the delivery of good patient care by future physicians.3–8 Previous research shows that students’ professionalism lapses occur in four domains, the so-called 4 I’s: lapses in involvement, integrity, interaction, and introspection.9 Additionally, patterns of professionalism lapses indicate that a lack of reliability, insight, and adaptability are aspects of unprofessional behavior.10–12 Contributing factors are often a combination of individual influences such as deficits in cognition, skills, and attitude,13,14 and contextual influences from the learning environment.15–17 Despite a growing understanding of (un)professional behavior, better identification and remediation is hampered by educators’ reluctance to report it.18–21 Educators often consider remediation of lapses difficult and ineffective.18,22–24 Also, a wide variability among schools regarding professionalism remediation practices can be observed.25,26 Educators would be more willing to report professionalism lapses if policies regarding the management of professionalism lapses and the effects such management has on the learner were clearer to them.18
Models for managing professionalism lapses have been described in several theoretical papers. These models are of two types: specific models that target professionalism concerns, and general models that are applicable to knowledge, skills, or attitude problems.6,8,27–30 See Table 1 for an overview of these models and their major concepts.
Existing models are based on different levels of (under)performance of learners. In each model, the different levels have specific actors, rules, and regulations that the literature does not adequately describe. So far, it is unclear what constitutes the thresholds between the levels. From these prior publications, we can conclude that there is a need for empirical evidence that supports a more detailed and explanatory model for attending to professionalism lapses.
Therefore, the goal of this study was to explore views of expert faculty on the guidance of medical students’ unprofessional behavior, informed by behavioral profiles outlined by previous research.10 These empirical data were used for the development of a model: a road map for attending to medical students’ professionalism lapses. Our underlying research question was: How do expert educators, who are responsible for remediation of professionalism lapses, make choices for interventions for undergraduate medical students who display lapses in professionalism?
We employed a grounded theory approach to conduct this study,31,32 as it allowed us to develop an understanding, and propose a theoretical model regarding the management of professionalism lapses. A grounded theory approach is often used as an inductive method but can also be used to build further on existing knowledge.33 In this study, the data acquisition and analysis was guided by findings from our previous research.10,34
We used a constructivist paradigm, in which knowledge is seen as actively constructed and cocreated as a result of human interactions and relationships.35 Among the author team, we are all educational researchers and/or medical educators experienced in teaching and guidance of medical students’ professional behavior. Our shared vision on professional behavior is guided by this experience and by our earlier research on this topic. M.M., G.C., and R.A.K. are general medical doctors, W.M. is a practicing clinician, A.T. is an education researcher, and A.C. is a linguist. M.M. and W.M. are actively involved in the guidance of students who display unprofessional behavior. As the other authors have more distance from the daily practice of medical education, they ensured that conclusions were not drawn too prematurely, and were grounded in the data. To consider our own contribution to the research process, and thus to enhance the trustworthiness of our findings, we kept an audit trail that was regularly discussed with each other and debated in research meetings of the Department of Research in Education, VUmc School of Medical Sciences, Amsterdam, the Netherlands.
Procedures and participants
Between October 2016 and January 2018, we iteratively collected qualitative data through 23 open-ended in-depth interviews with 19 experts from 13 medical schools in the United States. A maximum of 2 participants per school were included. Four participants were interviewed twice as part of the iterative approach. Ten participants were current or former deans or associate deans, 7 were curriculum directors, and 2 were faculty members responsible for professionalism remediation at their school. All had, for at least three years, the task of supervising the remediation process for professionalism in their school and will in this article be referred to as a “professionalism remediation supervisor” (PRS). They were identified through accessibility and snowballing, meaning that people who were willing to participate in turn referred others. We sampled PRSs from 8 public and 5 private medical schools from 8 states across the United States, including schools founded between 1824 and 1972, to explore multifold viewpoints and perspectives from settings that possibly differ in the way professionalism lapses are managed. M.M. conducted the interviews, in which findings from a previous study were used as a starting point for an exchange of ideas about managing professionalism lapses (see Supplemental Digital Appendices 1 and 2, available at https://links.lww.com/ACADMED/A618). Participants were aware that M.M. is an experienced medical educator and researcher of professionalism. All interviews were audio-recorded and transcribed verbatim, after which the recording was destroyed. We continued sampling until the research team members collectively considered that sufficiently rich data had been gathered to have an adequate understanding of the processes underlying the choice for attending to professionalism lapses, and to be able to construct a model in the form of a road map.36
Three researchers (M.M., A.C., and R.A.K.) performed the qualitative analysis, concurrent with data collection. Using ATLAS-ti (Scientific Software Development GmbH, Berlin, Germany), initially one interview transcript was independently coded, (by M.M. and R.A.K.) using, but not limited to, our previous research findings. For the initial coding phase we used an early coding scheme originating from the pilot interview, which evolved in a constant comparative process of reading, coding, and discussing. On the basis of the initial findings we employed additional sampling. After analyzing these additional data, a final set of codes and categories was established, and a preliminary model was drafted. For the second coding phase, M.M. recoded all transcripts using the final set of codes, discussing difficulties with the other coders. M.M. and A.C. went through the data a third time to especially look for any cases that would challenge the preliminary model. During the analytic process we used memos, diagrams, and minutes of research meetings to collect ideas. We raised the results from the categorical to the conceptual level through discussions with the full research team. By exploring relationships between the codes and themes, we aimed to understand the meaning of the data, thus finalizing the road map model for attending to professionalism lapses.
This study was qualified as exempt from ethical approval by the University of California, San Francisco Institutional Review Board (reference no. 176957).
On the basis of the interviews, we visualized how educators attended to students’ professionalism lapses as a three-phase process. Phase 1 was characterized as “explore and understand,” phase 2 was “remediate,” and phase 3 was “gather evidence for dismissal.” The threshold between phases 1 and 2 appeared to be constituted by the underlying causes for the lapse. The threshold between phases 2 and 3 appeared to be constituted by the student’s reflectiveness and (lack of) improvement.
Each of the three phases differed in the goals to be achieved, the individuals involved, the type of activities undertaken, and the reasoning behind decisions that were made. Individuals that the participants described as being involved in remediation were the (associate) dean, course directors, regular (clinical) teachers, remedial (clinical) teachers, experts outside the school, members of promotion committees, and sometimes members of Student Honor Councils. For each phase these individuals fulfilled different roles. In phase 1 these individuals had the role of a concerned teacher, in phase 2 that of a supportive coach, and in phase 3 they became gatekeepers of the profession. Participants’ remarks illustrating each of these phases follow; speakers are identified by participant number.
Phase 1: Explore and understand
After a student had been cited for a professionalism lapse, PRSs reported holding a conversation with the student, in which the PRS initially sought the student’s understanding of what happened and the emotions regarding the lapse:
The first question that I ask the student when he comes into my office is probably just: “Explain to me what happened.” (P2)
In this phase the PRS was tasked to understand what personal or contextual factors influenced the behavior:
We have to look at what the underlying issues are, whether it’s you’re just not taking it seriously, or there are other issues going on in their life, or is it drug and alcohol abuse or is it depression? Any number of things. Knowing what the underlying features are is much more important to us than just the behavior itself. (P12)
One PRS recognized that an additional and important goal of the initial conversation was to show that the school takes professionalism seriously. PRSs felt that students are developing physicians who can accidentally behave unprofessionally. Hence, in phase 1, the PRS assumed the role of a concerned teacher who aims to support and help, not to punish the student, as is evidenced by this quote:
Even though I’m not going to penalize the student, they have to come and talk to me and they know that their behavior was noticed. I think that’s kind of powerful itself. Without any penalties or anything like that. For someone simply to know: “Oh, actually, they take this seriously.” (P12)
In this phase, PRSs reported often encountering a conflict of interest about being allowed to “diagnose” a learner:
I’m very, very reluctant to give any student any kind of diagnostic label whatsoever. You know, there are clear, strong reasons for that. At the same time, it’s impossible for me to eliminate my mental health knowledge and insight from my role as an educator. (P5)
Interview responses show that the PRS and the student would ideally arrive at a mutual understanding about the contributing factors for the professionalism lapse, which were classified as personal, external, interpersonal, or contextual. See List 1 for a list of contributing factors that were mentioned by the participants in this study.
In the case that both the PRS and student were of the opinion that the lapse was accidental, and there was no further need to prevent repetition, participants indicated that the student continued her or his education in the normal curriculum. If both agreed that the student needed further support (e.g., to fill in a knowledge gap or to develop certain skills), the student was offered remediation, and phase 2 commenced.
In the case of unlawful behaviors, the student sometimes immediately moved to phase 3. It seemed that such immediate dismissal was exceptionally rare and would only be considered in the case of an extreme event. As one participant stated:
Although, I would say that even for dismissal, it’s unusual to be an event of such magnitude in the absence of other data that would result in dismissal. (P16)
Phase 2: Remediate
The goal of this phase was to improve students’ ability to reflect, and for students to overcome identified deficiencies in knowledge, skills, and competencies that contributed to the professionalism lapses. Therefore, individual support was offered for difficult personal factors or external contributing factors for the lapse, although participants acknowledged that these issues were hard to solve. In collaboration with the student, a remediation plan was set up that described interventions tailored to the student’s personal needs. PRSs described creativity in designing remediation interventions, and considered different options, each with its specific goal: assignments to improve the knowledge base of professionalism and to clarify the consequences of unprofessional behavior for (aspiring) physicians and patient care; skills training to improve specific skills and create the student’s awareness about own performance; or one-to-one mentoring to teach values and offer guided reflection on experiences. PRSs often chose a core faculty member with adequate expertise to conduct the remediation:
They’re often people who we know do this well, but they’re respected faculty. Students respond to them well, students respect them. Handpicked, yeah. (P10)
In this phase the PRS and remedial teachers were described as supportive coaches. The expectations and consequences of not reaching the goals were set out clearly, including a time frame in which improvement must be reached:
You would probably say if we don’t see an improvement here, we’re going to take this to the Professionalism Committee or we’re going to take this to the Promotions Committee. You’re at risk of being dismissed for unprofessional behavior if we don’t see an improvement here. (P9)
Participants mentioned an unintended effect of professionalism remediation. Some students seemed to “play the game,” which was described by the participants as displaying desired behaviors to satisfy their educators, without having internalized the values of professionalism:
Sometimes the student succeeds not because we have helped them reach an epiphany, but they have decided that they will play the game and they will make it right. They will follow the rules, they will cross their t’s, they will do what is necessary: “I’ll do it and then I will just get through this place.” (P12)
This type of unprofessional behavior was described by the interviewees, yet no ideas on how to deal with the “gaming” student came forward from the data.
Phase 3: Gather evidence for dismissal
The threshold between phases 2 and 3 was crossed if the problem appeared to persist despite remedial teaching, and if the student displayed dishonest or even unlawful behaviors. In these cases, patient safety was deemed to be threatened:
When things are severe in that regard, we have concern for patients, for public safety, then we make use of that. (P17)
Sometimes participants reported a student lacking insight into the consequences of his or her behavior for working in a medical environment. Consequently, the student was not willing or able to reach the professionalism expectations. According to PRSs, this could result in repetitive professionalism lapses without improvement, despite individualized remedial teaching:
If the student doesn’t see that what they’re doing is a problem and doesn’t change, they’re likely to repeat behavior. That’s what gets students dismissed from medical school. (P4)
In phase 3, PRSs were of the opinion that further remediation would not be effective anymore. As one educator stated:
I don’t have a … I have a pessimistic feeling at the beginning, but I try to keep hope. There have been a handful of students I just felt like it would take.… The kind of work it would take to get them to have that insight or the ability wasn’t in our tool kit. (P14)
Strong evidence had to be obtained for dismissal, through very clear processes:
We have to demonstrate that we’ve done everything. (P14)
You have to have a committee, you have to have clear processes, before people can get dismissed. There’s only two ways you can be promoted or dismissed. It’s the Judicial Board or the Committee of Student Promotion. Those are the only two ways. (P6)
The responsibility for deciding about continuing the studies was not in the PRS’s hand but, rather, belonged to a promotion committee. Promotion committees could be reluctant to take the tough decision to dismiss a student:
I’ve been in four medical schools and the culture is the same in all those schools. There’s a real reluctance to dismiss students once they’re admitted to medical school. There’s a lot less reluctance to dismiss students from lots of other academic programs than there is in medical school. (P9)
In phase 3, PRSs reported taking up a completely different role than in phases 1 and 2: They became the gatekeepers of the medical profession. Although they took this role seriously, they found it difficult to conclude that a student should not be allowed to become a doctor. PRSs had to notify the medical school promotion committee with information to justify dismissal. Going from collaborator to opponent, PRSs described experiencing a conflict in choosing between the interest of the student and the interest of health care and patients:
I think there’s always a bit of a difference to give the student an opportunity to succeed. Sometimes the people making the decisions about whether or not a student can come in, it’s a committee that’s different from those who have been working with the student. It can be good that people don’t get tied up in the personal relationship. It can be bad if the people making the decisions don’t seek or get input from everyone who’s been involved with not only getting the student’s perspective, but everyone else, and knowing what some of the problems were. (P13)
Furthermore, participants acknowledged that remediation is a demanding task that has to be shared among a group of teachers:
The sad part of what happens is—I have had this position now for over 15 years—that I find that each school the people I know that are good at this … I have to be careful not to just continually use them repeatedly. First of all, it tires them out. You also then are giving other people opportunity back when there’s opportunity to learn how to do this. (P1)
The road map model
Analyzing and relating the data prompted us to develop a road map model that describes the process of attending to professionalism lapses of medical students. Figure 1 depicts this road map. PRSs consider the first phase as regular teaching, and only the second phase as remediation. If, after a concerted effort to remediate unprofessional behavior, the conclusion was drawn that the student should not be allowed to continue the medical studies, the third phase would start. In this last phase, the role of the PRS as gatekeeper of the profession competes with the role of concerned teacher and supportive coach.
Table 2 shows participants’ quotes delineating examples of student cases per phase: two examples that fit neatly into each phase, and one that does not as well.
Our purpose in this study was to create a model for attending to professionalism lapses by unraveling how faculty responsible for professionalism decide about interventions for students who display lapses. Our findings can be grouped into three phases: (1) explore and understand, (2) remediate, and (3) gather evidence for dismissal. In addition, results suggest that clear thresholds exist between these phases. The threshold between phases 1 and 2 is determined by the mutual understanding of the PRS and student that remedial teaching is necessary, based on the perceived contributing factors of the lapse. A lack of reflectiveness and adaptability, as evidenced by an ongoing pattern of lapses despite remedial teaching, is seen as a reason to proceed to phase 3, and thus forms the threshold between phases 2 and 3. Participants expressed that a lack of reflectiveness and adaptability by students can lead to potential compromises of patient safety. PRSs have different roles in the three phases, which can create conflicts of interest. The road map delineating the three phases provides a guideline to faculty for attending to professionalism lapses of undergraduate medical students.
What this study adds to existing models
Our findings provide empirical support to earlier proposed models more generally describing phases in the process of attending to professionalism lapses.6,8,27–30 What we designate as phase 1 resembles the first phase in all previous models: the “cup of coffee” conversation as proposed by Hickson and colleagues.27 Our findings indicate that in phases 1 and 2, the approach to remediation is guided by the contributing factors for the behavior, and how the student responds to feedback. This finding contrasts with existing models in which the phases are based on the perceived severity of the professionalism lapse.6,8,27–30 Also, according to previous research, severity of the behavior is most often cited as the reason for dismissal from school for professionalism deficits.24 We do confirm that remediation is scaled up if the student does not show improvement of performance, despite remedial interventions: Recurrent professionalism lapses, regardless of the cause, point to phase 3. In contrast, according to the findings in our study, in the last phase of the process neither the severity of the behavior nor causal factors seem to be important. We found that a student’s lack of insight and improvement determines the threshold to the last phase. This is in line with Krzyzaniak and colleagues’12 findings among residents. If a student does not show progress in reflectiveness and adaptability, she or he will no longer be absorbed into the culture of the community of practice. This can lead to dismissal. These findings add to existing models.6,8,27–30
Kalet and colleagues37 advocate that remediation should be a part of the curriculum, which is supported by the findings of our study. Remediation strategies, as applied in phase 2, do not in essence differ from normal teaching methods. The difference is that the PRS needs to have “above average” skills. PRS participants in this study confirmed that remediation is a demanding task for which they need to handpick teachers, and give support to these individuals because their work can be energy consuming.1 Clearly, faculty could benefit from working together to share their experiences and improve expertise in the medical school.2
Congruent to the normal curriculum, participants sometimes noticed “gaming the system” behavior by their students, meaning that students show desired behaviors without having incorporated the lacking professional values. Possibly, the focus on behaviors and professional development diminishes the attention for traditional virtues.26 This finding confirms that the knowledge base of professionalism values is foundational, and that skills training has to be combined with activities to improve the student’s professionalism values to prevent such behavior.5,6
The phases and the community of practice
A surprising insight was that the different remediation phases could be interpreted using the framework of communities of practice to add further insights to attending to professionalism lapses.38 As Cruess and colleagues39 state, this framework can serve as the foundational theory for medical practice, as it “does not in any way affect the validity or usefulness of other theories,” yet can provide a useful background for most other theories. If we view medical practice as a community of practice, the student journey at the medical school progresses from legitimate peripheral activities to full participation and membership, coming closer and closer to the core of the community. Professional behavior can be seen as a common value of the community, practiced by those in the core—competent physicians. Unprofessional behavior, however, is not the standard in the community, and can be a signal that a student needs help in his or her journey into the community.
Taking this a step further, we can look at the relationship between our three-phase model of attending to professionalism lapses, and the communities of practice framework (see Figure 2).
In our three-phase model, the first phase assumes that the student is still in the process of joining the community. There has been a lapse in professionalism, yet the approach to the student is friendly, open, and helping. The individuals involved in remediation make a concerted effort to include students into the community, and their role is one of a concerned teacher or colleague. In the second phase, the intention seems to slowly shift, as in this phase the student needs to prove that he or she is willing and able to develop the skills to stay in the community. To steer the student back onto the journey into the community of practice, participants mentioned forms of mentoring and matching the student to role models. Our road map shows that indeed, while the goal is to approach the student as still being eligible for staying in the community, conditions are being laid out, and it is made clear that the student needs to meet the requirements. In phase 3, however, the student no longer moves from the periphery to the center, but in the other direction, by not adhering to the expected practices. In this phase, core values of the medical community are threatened. This is where we see the initiation of a reverse process: Effort is put into guiding the student out of the community of practice.
The results of this study may offer medical educators a theoretical base for attending to students who display professionalism lapses. According to the concept of communities of practice, social relations are important to bring an individual into the core of a community.38 When remediation takes place outside the regular educational context, it can lead to isolation of the student. This can make it even more difficult for the student to enter the community. This implies that, during remediation trajectories, attention should be given to the need for connection with other learners and educators.
Context influences behavior, which is confirmed again in this study.15–17 PRSs are informed about contextual contributing factors for professionalism lapses, and they can use that information to make changes in the institutional culture to prevent medical students’ future lapses.
The interviews were guided by findings from our earlier research, which theoretically could have limited the discussions or biased the participants. We deliberately chose this approach as we are of the opinion that it was an advantage to build further on earlier research findings.
The reality of attending to professionalism lapses is complex, as many serious professionalism problems involve uncertainty and differences of opinion, which can be difficult to sort out. Our findings are the result of an attempt to extract useful information from experts in the field to develop a model for handling professionalism lapses. This extraction might not be 100% correct, but yet useful for people who have to attend to professionalism lapses in medical students.
Furthermore, where judicial and financial aspects of studying medicine in the United States differ from those in other countries, the findings are specific for the United States and need to be tested in other contexts to make them generalizable to other countries.
It was beyond the scope of this study to examine the effect of remediating strategies; future research should focus on the effectiveness and efficiency of specific remediation activities such as those applied in phase 2.
The threshold between phases 1 and 2 is constituted by behaviors and their causes, and is thus highly context dependent. Future research should examine contextual influence on this threshold. Such research could also further refine the description of the threshold between phases 2 and 3, and thus underscore the evidence to dismiss (or not dismiss) a student from the medical school.
This study might stimulate the medical education community to consider the way medical students are guided or sent out of a community of practice. Whereas we found substantial prior research about entering such a community, we were not able to find literature about exiting a community of practice, whether it be voluntary or forced.
The findings of this study prompted the development of a three-phase explanatory model for attending to medical students’ professionalism lapses that fits well in the overarching framework of communities of practice. Whereas phases 1 and 2 are aimed at keeping students in the community of practice, phase 3 is aimed at guiding students out. These findings provide empirical support to earlier proposed models describing the phases in the process of handling professionalism lapses, and may offer medical educators a theoretical, now empirically founded, base for approaching students who display such lapses.
Contributing Factors to Lapses in Professionalism According to the Professionalism Remediation Supervisor, From a Multi-Institutional Study of Educators’ Response to Medical Students’ Professionalism Lapses, 2016–2018
- No knowledge base of professionalism
- Competency deficits
- Personality disorders
- Asperger or autism spectrum-type symptoms
- Other mental health issues
- Physical health issues
- Substance abuse
- No motivation for medical school
- Language difficulties
- Family issues
- Financial challenges
- Racist microaggressions
- Different cultural expectations
- Professionalism expectations have not been clarified
- Feeling overwhelmed by stressful circumstances in the workplace
- Frustration about organization of health care
- Learning environment not as good as it should be
- High expectations in medical school
- Poor role modeling
- Unwarranted evaluation
Acknowledgments: The authors wish to thank the participants for generously contributing their time and expertise.
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