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Responding to the Professionalism of Learners and Faculty in Orthopaedic Surgery

Arnold, Louise

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 205-213
doi: 10.1097/01.blo.0000224034.00980.9e
SECTION I: SYMPOSIUM II: Professionalism

Recent developments in assessing professionalism and remediating unprofessional behavior can curtail the inaction that often follows observations of negative as well as positive professionalism of learners and faculty. Developments include: longitudinal assessment models promoting professional behavior, not just penalizing lapses; clarity about the assess-ment's purpose; methods separating formative from summative assessment; conceptual and behavioral definitions of professionalism; techniques increasing the reliability and validity of quantitative and qualitative approaches to assessment such as 360-degree assessments, performance-based assessments, portfolios, and humanism connoisseurs; and systems-design providing infrastructure support for assessment. Models for remediation have been crafted, including: due process, a warning period and, if necessary, confrontation to initiate remediation of the physician who has acted unprofessionally. Principles for appropriate remediation stress matching the intervention to the cause of the professional lapse. Cognitive behavioral therapy, motivational interviewing, and continuous monitoring linked to behavioral contracts are effective remediation techniques. Mounting and maintaining robust systems for professionalism and remediating professional lapses are not easy tasks. They require a sea change in the fundamental goal of academic health care institutions: medical education must not only be a technical undertaking but also a moral process designed to build and sustain character in all its professional citizens.

From the University of Missouri-Kansas City School of Medicine, Kansas City, MO.

The author certifies that she has no commercial associations that might pose a conflict of interest in connection with the submitted article, that she has and will not receive payments or benefits from a commercial entity related to this work, and that her institution has not received any sort of support in connection with this work.

Correspondence to: Louise Arnold, PhD, University of Missouri-Kansas City School of Medicine, 2411 Holmes, Kansas City, MO 64108. Phone: 816-235-1806; Fax: 816-235-5277; E-mail:

On the mid-rotation evaluation, the director of medical education noted the chief resident's remarks about Ms. Martin, a medical student in the orthopaedic surgery elective: “Student should read more; spends too much time with patients.” Later, a social worker dropped by the director's office. In passing, she commented that Ms. Martin was a great addition to the service. She had asked the social worker how to find help for a patient's alcohol problem after she heard a resident tell the patient, “If you come in again, drunk, with another broken bone, I won't fix it.”

The residency director in orthopaedic surgery heard a commotion in the scrub room. Peering around the corner, she saw a second year resident, Dr. Rudd, gesticulating at one of the OR nurses and then throwing his cap at her. She recalled a conversation a few weeks prior with a colleague who bemoaned Dr. Rudd's angry outburst when the nurses did not promptly respond to a patient's call button. She thought her colleague's comment was ironic, for he himself had a reputation for occasional tantrums in the OR.

To respond to the behavior of the student, the residents, staff, and faculty colleague, or not to respond, and how, are the issues the medical education director and the residency director must resolve. And those are the issues explored in this paper: responding to behavior related to the professionalism of students, residents, and faculty physicians in orthopaedic surgery. First, I will describe the patterns of responses to professional and unprofessional behavior apparent in our collective experience and the literature. Then, I will identify factors that contribute to those responses. Next, I will review models, principles, and programs for responding to the professionalism of learners and colleagues through assessment and remediation. In closing, I will recognize the role of institutional environments and individuals in supporting responses to professionalism.

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Response Patterns to Behaviors

We know we should respond to the professional or unprofessional behavior of learners and colleagues. But all too frequently we are silent.34,59 We do not notice the behavior or, if we notice it, we ignore it. We are inclined to remain silent about exemplary behavior and excuse, rationalize, or lament lapses in professionalism.

We are not alone. In focus groups, some students in two midwestern medical schools questioned whether a peer should be lauded for acting professionally, that is, for doing what is expected.7 Other mechanisms for acknowledging professional behavior, such as honor societies, are a recent phenomenon.9

Reluctance to respond is especially evident in the face of a professional lapse, as suggested by early work on assessing clinical performance.72 Students and residents are ambivalent about telling anyone in authority about a peer's unprofessional behavior.7,20,71,75 Students report some faculty ignore the unprofessional behavior of learners,7 and other research verifies their contention.31 In another study, faculty recorded students' and residents' unprofessional behavior on comment cards but did not identify these learners as unsatisfactory.61 End of rotation ratings and comments fail to detect or report deficits of surgery residents, especially deficits in professional behavior.65 Literature on impaired and disruptive professionals refer to the blind eye and a conspiracy of silence.16,57,67

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Why the Silence?

There are many factors contributing to our inaction, including societal and professional values and the organization of our healthcare and medical education institutions. Our society frowns on whistle-blowing, and so do our learners.7,60 Our professional values of helping but doing no harm enjoin and discourage action when faced with an unprofessional colleague.36 Our institutional hierarchies foster the idea someone else should respond to the professionalism of learners and colleagues; and the prospect no one will act, especially the administration, depresses our responses further.41

Circumstances surrounding the assessment of professionalism and remediation of unprofessional behavior lie at the core of our silence.21 Financial pressures constrict faculty time for interacting with learners and each other.32 Large classes, rotation of learners through clinical settings for brief periods of time, along with resident work hours,32 diminish the faculty's ability to observe the professional development of learners. The emphasis on technical knowledge and skill plus the technological and scientific successes in surgery shortchange the attention we pay to the art of medicine, where so much of professionalism lies (as I articulated in a keynote address “Closing the loop on unprofessional behavior: medical education as moral education” presented at the Spring Meeting of the Southern Group on Educational Affairs, Group on Educational Affairs, Association of American Medical Colleges; April 15-17, 2004; Savannah, GA. and as noted elsewhere).17 Faculty may not have the tools to quantify their impressions of learners' unprofessional behavior in ways that ensure consistent comparisons across evaluators.54,55,58 Thereby they feel assessment of professionalism is not objective, an abrogation of the value they place on reliable and valid measurement. Additionally, learners are bothered by the posited subjectivity of assessing professionalism.7

Yet, the very nature of assessing professionalism requires us to make noncontent-oriented judgments about learners' and colleagues' behavior. Assessment of professionalism requires us to consider the inner world of a human being, but we prefer to deal with the outer world of observable behavior.80 It demands reflection, but we stress action.6 Compliance with laws and norms regarding confidentiality constrain faculty and learners from hearing about the successful responses to lapses in the professionalism of colleagues.

Individual students, residents, and faculty may find it difficult to discuss unprofessional behavior with the person involved, to write a report about it, and to deal with the potential consequences, intellectually and emotionally. Learners and practicing physicians worry their perceptions of the behavior of a colleague or learner might not be accurate, the professional lapse may be only transitory, or the behavior in question may not be unprofessional because the concept of professionalism is fuzzy. (It may well be difficult to differentiate, for example, between the committed practitioner who demands excellence and the disruptive practitioner.) Learners and faculty struggle with the prospect that discussing the lapse with the person and/or reporting it may impair working relationships,7,41 and open them up to criticism or retaliation. They are concerned about the prospect of an appeals process,21 or litigation,58 and are suspicious of the legal system.72

In the same way, circumstances surrounding remediation of professional lapses contribute to our failure to respond to unprofessional behavior. Although a number of accrediting bodies require policies and procedures for responding to professional lapses, the policies may not be well-publicized. Thus, uncertainty arises about the reporting process, about provision of due process and the consequences for the lapsed learner or physician, and about protection for the person who files a report. Faculty may perceive that options for remediation are absent.21 Remediation can appear unduly intrusive and for a practicing physician antithetical to the right to practice without interference as long as she or he meets professional standards and behaves ethically.36 Remediation itself requires resources and can disrupt workflow. Outcomes of the remediation process may be ambiguous, and at least some unprofessional behavior may not be amenable to remediation.

Given these circumstances and concerns about assessment and remediation, the conclusion can be: responding to professional behavior, especially unprofessional behavior, is not worth the effort. However, recent developments negate that conclusion. Models, principles, and programs for assessing the professionalism of learners and colleagues and for remediating unprofessional behavior are available.

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Assessment of Professionalism

Several models for assessing professionalism have curtailed the silence surrounding the assessment of professional lapses.54,55,58,74 Their goal is to help, not penalize, students. The models provide for the longitudinal assessment of learners' professionalism from the first year of medical school onward. One of the models invites faculty, resident physicians, and administrative staff to assess learners' professionalism as a supplement to regular faculty assessment in courses and rotations.58 A second model requests course directors to file a report if a student receives less than solid ratings for professional skills in a course.54,55 The third encourages confidential submission of an early warning note if a student's behavior in a course is concerning but not serious enough to impact a final grade.74 A central figure, such as an associate dean, meets with a student for exploration of the allegations, remediation as required, tracking, and followup in a safe environment. While allowing for professional growth, the models hold out the prospect for probation and dismissal if necessary. To address faculty concern that assessment of professionalism is subjective, these models use assessment forms, allowing evaluators to quantify their judgments more consistently and to offer their comments. Studies based partly on data from one of these models show an association between unprofessional behavior in medical school and subsequent disciplinary action by a state medical board when the students became practicing physicians and identify domains of unprofessional behavior related to this discipline.53,56,70 Although these models identify students who have acted unprofessionally, they neither offer explicit feedback to all learners nor appropriate recognition to those who have shown exemplary professionalism.

Global performance ratings can provide feedback to all individuals assessed. They are a predominant assessment method across the continuum of medical education,42,82 including assessment of professionalism in orthopaedic surgery, according to private communication from RL Cruess MD, Professor, Faculty of Medicine, McGill University, October 6, 2005. But this assessment approach generally suffers from unwanted sources of score variation.42,81,82 The task of assessing professionalism magnifies at least some of these sources of bias.81 At the same time, principles related to the why, what, when, and how of assessment can be derived from the literature to improve assessment of professionalism.

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Why Assess Professional Behavior?

The purpose of assessment in its broadest sense is to inform decisions made about and by learners and faculty and about programs.69 Good assessment is a form of learning and should provide guidance and support to address learning needs of trainees and educators.24 It also provides evidence for certification of competence of learners and quality of programs.24

Often assessment has a mixed function, particularly assessment of professionalism as it requires a summative and a formative function. The Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) require evidence that learners and programs have met standards for professionalism so certifying decisions about learners' progress and program quality can be made.2,39 The process of acquiring professional values and incorporating them into a professional identity also requires formative assessment, for it is clearly a developmental process.25,51 The process can be prolonged,68 entails continual striving,8 and depending upon the knowledge, attitudes, and values individuals bring with them to the medical education arena, does not progress in a linear fashion.45,77

Transparency about whether an assessment will be used formatively or summatively is important to the acceptance of the assessment by evaluators and those who are evaluated and to the quality of information collected.66 Yet, the need to undertake formative and summative assessment of professionalism remains and points toward an assessment track for growth and another for certification. Such an arrangement may encourage evaluators to provide authentic feedback and may reduce a sense of manipulation among learners and colleagues who receive the feedback. The suggestion learners receive immediate meaningful feedback about their clinical performance after direct observation32,81 alludes to the possibility of two tracks for assessing professionalism. Other suggestions for separating formative from summative assessment include limiting end of course and/or end of rotation assessments to only reporting observations of learners' behavior81 and using a committee to discuss learners' behavior and assign a grade and/or make a decision about learners' progress.31,65 Committee discussion appears especially effective for identifying performance deficiencies.31,65,81 A scheme in which faculty monitor behaviors to assure learners meet minimum standards and learners take responsibility for professional growth beyond the minimum may be adaptable to and useful in the assessment of professionalism, at least in graduate and perhaps continuing education.29

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What is Being Assessed?

Good assessment is clear about what is being assessed. Clarity is especially important in the assessment of professionalism, a complex concept many perceive as poorly delineated.8 A deliberate discussion among faculty and learners can elucidate the meaning of professionalism that should guide the assessment. Although time-consuming, broad participation of faculty and learners in defining professionalism for assessment purposes is important, for it can contribute to better assessment. It can promote common understanding among evaluators, who may then achieve greater consistency in observing, describing, and judging behavior. It also can educate learners about professionalism and meet their announced need to know the standards by which they will be judged.7,21

Starting points to define the concept for orthopaedics are legion, including charters, statements of principles, and codes of medical ethics.1,3-5,30 The richness of these documents, however, does not easily produce transparent operational definitions for assessment. Unifying more parsimonious definitions, more appropriate for assessment, have been offered.8,19 They lay out the essential principles of professionalism, eg, the aspiration toward and wise application of excellence, humanism, accountability, and altruism.8 These principles may be additionally consolidated into those centered on the physician's healing role with obligations to patients and families and the professional role with obligations to the medical profession, other healthcare professionals, and society.18,30

Once clarified, the conceptual meaning of professionalism must be translated for assessment purposes into expectations for learners and colleagues and then into indicators of whether expectations have or have not been met. Results of a consensus conference of the Academic Orthopaedic Society,64 a set of behaviors developed by the National Board of Medical Examiners,50 and reflection on everyday experience of faculty can inform the creation of expectations and indicators.

In developing expectations and indicators, the question of whether the principles of professionalism apply equally across the continuum of medical education emerges.6,8 Arguments pro and con have been offered, especially regarding the professionalism principles related to the social vision of medicine and the social contract.6,8,13,22,28 Using indicators of professionalism specific to the activities assigned to students, residents, and practicing physicians while holding them responsible for demonstrating each of the professionalism principles is one resolution to the problem.6,8 For example, participants in medical education, across the continuum, would be expected to demonstrate accountability but through stage-specific expressions of the principle, such as medical students paying tuition by the due date and residents and faculty completing medical records in a timely fashion. Another way to tailor the assessment of professionalism across the continuum of medical education involves Miller's pyramid of learning6,8: knowing, capacity to apply, and actualization in practice-the “know, can, do” schema.46 Different levels of learning of each principle of professionalism would be expected and assessed, depending upon the physician's stage of medical education.6,8 Adopting this approach, the longitudinal assessment of the ethical development of residents provided for progressive testing of knowledge at Year 1, then knowledge plus competence at Year 2, and finally knowledge, competence, and demonstration in Year 3.38 A similar scheme teaching and tracking moral reasoning of residents in orthopaedic surgery10 may be more generally adaptable to assessing professionalism.8 Moreover, this approach recognizes professionalism consists of three components: knowledge, skills or competence, and actual performance. Each of these domains requires assessment to achieve a profile of the strengths of learners and their deficits, which in turn may provide insight into potential sources of a professional lapse and ways to address those deficits.

Another important issue in developing expectations for and indicators of professional behavior for assessment purposes is specifying the cut points where, on the one hand, behavior will be recognized as exemplary and where, on the other, behavior will not be tolerated.30 Discussion among faculty, perhaps with input from learners, can determine these cut points after they understand the various needs for assessment of professionalism. These needs include guidance to foster professional development of learners and faculty, early identification of professional lapses in an effort to prevent subsequent sanctions, meeting accreditation standards of educational programs and health care facilities,2,39,84 and reduction of the considerable costs attendant to toleration of ongoing unprofessional behavior.57,84 Then technical decisions about which scale values will signify exemplary and unsatisfactory behaviors; which behaviors will constitute minor infractions of the standards of professionalism and how many minor infractions will be cause for concern; and which behaviors will be viewed as definite violations of the standards of professionalism and which will be seen as causes for reward and celebration must be reached. In making these decisions, consideration must be given to the intentionality of the behavior, the context in which it occurred, the reasoning underlying the behavior, and the behavior's potential for harm or for good. A professionalism mini-evaluation exercise, shared in a personal communication from RL Cruess, MD and SR Cruess, MD, Faculty of Medicine, McGill University, October 6, 2005, reflects such considerations. For example, being late once could be acceptable because the resident was caring for a patient in an emergency, but unacceptable if the resident was late for frivolous reasons.

Similarly, a transparent policy stating the consequences of exemplary and unprofessional30 behavior must be written. Models, previously described,54,55,58,74 and another described below,73 contain the beginnings of a template for writing such a policy. In formulating the policy consideration should be given to whether the intent is to merely identify and discipline the “bad apples,” designate and celebrate the exemplars, certify professionalism of all members in a department or program, and/or provide information to guide the professional development of learners and faculty.

The understandings reached about what will be exemplary, acceptable, and unacceptable professional behavior and the consequences of that behavior, codified into a policy, must then be clearly communicated to all involved in the assessment-those individuals who will conduct the assessment and those who receive it. Dissemination of the policy can occur through electronic or more traditional media as well as required educational seminars. Signed statements by participants that they have read, understand, and accept the policy are advisable. Symmetry in applying the policy to learners and faculty alike is critical for the viability and integrity of the assessment.66

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When and How to Assess Professionalism?

The nature of professionalism influences when and how it should be assessed. Because professionalism develops over time, it requires longitudinal assessment. Professionalism is context-dependent27 and appropriate opportunities must be provided to learners and colleagues to practice and demonstrate the full-range of professionalism principles. If, for example, learners are expected to demonstrate their civic professionalism, then they must be exposed to community-based settings where they can practice it.17,22,30,52,78,79 The context dependency of professionalism also necessitates multiple observations by a variety of observers including peers, nurses, and patients over a range of learner and physician activities, just as the assessment of other dimensions of competence requires.24,81

There are a number of ways, based on assessing clinical performance in general, to increase the likelihood that observing, judging, and reporting professionalism are appropriate. For example, strategies to improve resident appraisal based on global rating scales may be adapted to assessing professionalism. These include immediate documentation of observations to promote accuracy and the use of simple rating forms containing a list of professionalism principles so residents' strengths and weaknesses can be quickly checked.81 As a supplement to global rating scales, performance-based examinations can widen the sample of learner tasks and contexts in which assessment occurs;81 and they have been shown to be reliable and valid for assessing professionalism of residents in surgery and other specialties.12,76,85 The use of 360-degree assessments conducted by a variety of health care professionals has been recommended as an improved technique that provides a more complete profile of a physician's professionalism.15,44,49

Although much of the assessment of professionalism relies upon quantitative techniques, qualitative approaches are especially appropriate for assessing professionalism.33,47 They allow rich documentation of growth in professionalism over time. They can promote reflection among evaluators and the individuals being assessed to discover the meaning of context-dependent observed behavior.33 They allow for exploring how and why learners and physicians resolve the conflicts they face in choosing which of several equally worthy principles of professionalism will guide their behavior.6 They can reveal how learners wrestle with the gap between the principles of professionalism as ideals and the principles as lived.6

Humanism connoisseurs akin to art critics can facilitate the qualitative assessment of professionalism.47 Connoisseurs have expert knowledge, sensitivity, experience, and vocabulary to observe and offer a rich descriptive critique of the professionalism of learners and physicians.23 Other qualitative approaches rely upon the tradition of storytelling in medicine33 or apply rhetorical analysis.40 Essays, diaries, projects, creative products-collected in portfolios over time26-can be subjected to qualitative assessment. Each approach has a method to yield reliable and valid insights into the professionalism of students, residents, and physicians.

To improve assessment along the lines just described requires a systems-approach. Such an approach has been successfully employed to diagnose and address problems in assessing surgery residents' performance, including behavioral specificity of narrative comments,42 and it may be adaptable to the assessment of professionalism. It recognizes the need to attend to the role of the individual evaluator, the program director, and an infrastructure with incentives and consequences for evaluators, training to use the assessment form, and staff assistance. The use of evaluation champions (ie, faculty with experience and interest in assessment who can mentor and teach other faculty about assessment) and on-going evaluation of the assessment system are additional recommendations for achieving accurate and useful assessment of professionalism.32,81 Exploring how well an assessment system promotes professionalism is warranted; experiences of faculty and students with the assessment may indicate the system deters professionalism.7 As an example, in evaluating an assessment tool, investigators found unintended messages about professionalism embedded in the tool's text, according to written communication from Nehad El-Sawi, PhD, Kansas City University of Medicine and Biosciences, February 23, 2006.

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Remediation of Unprofessional Behavior

Better remediation of unprofessional behavior not only depends upon the improvement of the assessment of such behavior but also upon the use of models for remediation that suggest an effective general process and allied principles.37,73,83 After recognizing a learner or practicing physician has acted unprofessionally, notification and discussion ensue. If the complaint is severe, a formal investigation may be immediately scheduled. In other instances, discussion with the learner or physician may first take the form of a candid yet educational session, perhaps with suggestions for corrective action. Should the behavior not improve, intervention sessions become more direct and include an unequivocal warning about the consequences of continued inappropriate behavior. Bylaws and policies codify this method.59

The following principles are warranted in remediation of professional lapses. To evaluate the lapse, one must consider these dimensions: (1) how clearly the conduct violates the standards of medicine and the community; (2) how serious the lapse is, often a function of the actual or potential harm that may occur; and (3) whether the violation is intrinsically wrong.48

Then, because all deviations from professional standards are not the same, appropriate characterization of the problem, based on careful fact finding, can lead to appropriate remediation. Analyses of the dynamics underlying professional lapses can assist in the diagnosis of the problem and the selection of remediation. One of these analytic schemes focuses on levels of moral errors and suggests corresponding remediation. “Where ignorance is the problem, then education, not punishment or discipline, is the answer. Where poor ethics is simply misguided, not evil, then moral education may be in order. For deliberate exploitation of patients for personal gain, then responsibility and retribution are appropriate.”48 Similarly, categorization of professionals who have sexually exploited their clients into subtypes (depending, for example, upon the type and severity of psychological illness present) points to the selection of an appropriate therapy and the likelihood of rehabilitation.35 Various types of chemical users, ranging from social users to physically and psychologically dependent addicts, need different therapeutic approaches and face different chances for recovery.16 Clearly, remediation must fit the lapse.

Several kinds of therapeutic techniques can address lapses in professionalism. Notable here are cognitive behavioral therapy and motivational interviewing. The focus of these techniques is on the here and now, not the past, and the client is an active participant. An extensive review of many studies of cognitive behavioral therapy has demonstrated the effectiveness of that therapy.63 Some believe it to be the preferred treatment for a number of problems ranging from depression, anxiety, obsessions, and compulsions through poor coping skills, expression of anger, and relationship difficulties.14 Motivational interviewing evolved from the treatment of problem drinkers, and there is good evidence it benefits individuals who abuse alcohol but who are not dependent upon it.63 It is being used in treating clients with many behavioral difficulties.

Programs available nationwide can assist in addressing some of the underlying problems that manifest themselves in unprofessional behavior. Physician health programs and Assistance/Advocacy for Impaired Medical Students (AIMS) programs strive to help individuals with a variety of addictions ranging from sexual exploitation to drug and alcohol abuse. They may also address psychiatric problems. Programs for disruptive physicians, now available, are well-suited for addressing persistent and important lapses in professionalism.57

How effective are they? More than ¾of professionals who enter recovery programs for chemical addictions remain abstinent,16 although the dropout rate in some programs can be substantial (about 50%).62 About ⅓ of the sexually exploitative professionals have an excellent to good prognosis, and another ⅓ has a fair chance; for the remaining ⅓, professional life is by no means assured.35 A state physicians' health program for impaired and disruptive physicians reports a recovery rate of 90%.11 The efficacy of these programs rests upon such techniques as structured interventions based on confrontation to break through the defensive denial of individuals who have behaved unprofessionally to involve them in the remediation process; continual monitoring of behavior linked to behavioral contracts; and self-help groups in conjunction with other therapy and counseling (for example educational group therapy, anger counseling, and training in conflict management.) Continual intensive formal monitoring of behavior with feedback in an emergency medicine department has recently been shown in a case study (“A performance improvement plan in professionalism for the emergency medicine resident” presented by C Sullivan MD, J Quaintance PhD, and L Arnold PhD in a peer reviewed poster session at the Spring Meeting of the Central Group on Educational Affairs, Group on Educational Affairs, Association of American Medical Colleges; March 9-11, 2006; Kansas City, MO) to address the communication and professionalism deficits of a resident who through the process gained self-insight and assumed responsibility for altering problematic behavior.

The prospects for remediation of unprofessional behavior can be summarized as follows according to oral communication with GS Thompson, MD, Associate Professor of Psychiatry, University of Missouri-Kansas City School of Medicine, February, 2004. The chances for remediation and rehabilitation improve if the learner or physician has embraced the values of professionalism in the first place, if the learner or physician has some insight into his or her problem, and if he or she is willing to change. Chances also improve if the learner or physician expresses feelings about the problem such as remorse, guilt, or empathy for people who might have been harmed and if the learner or physician has a capacity to value relationships with others.

However, remediation and rehabilitation are not only dependent upon the individual learner or physician who has behaved unprofessionally. Success also depends, it appears, upon the nature, extent, and duration of the problem. The aptness of the match between the problem and the therapy, the skill of the therapist, and the match between the therapist and the individual learner or physician also matter. Because learners and physicians who have not acted professionally are often not alike, therapy needs to be tailored to the individual. Because it is easier to describe professional lapses than it is to explain them, treatments focusing on the here and now to change behavior may hold the most promise.

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The Role of Institutional Environments and the Individual

Mounting and maintaining robust systems for assessing professionalism of learners and colleagues and remediating their professional lapses are not simple tasks. They are, however, the quintessential expression of our professionalism.30 But, they require a sea change in our view of a fundamental goal of our academic healthcare institutions, as I argued in the keynote address at the Southern Group on Educational Affairs mentioned above. Just as others have articulated,30,34 we too must recognize that medical education must not be only a technical undertaking but also a moral process designed to build and sustain character of all its professional citizens. Put another way, the goal of medical education across its continuum is not merely to produce surgeons who are technically brilliant but also who continually strive to apply the principles of professionalism wisely. We will have minimally reached this goal if learners and faculty outwardly comply with the values of professionalism. We will have truly achieved our goal if our graduates, our colleagues, and we ourselves internalize the principles of professionalism, embracing them as our own. In turn, reaching that fundamental goal requires attention to the support the institutional environment gives to professionalism.

Institutional environments, of course, do not change by themselves. Individuals are the change agents. So each of us, each learner and faculty member in orthopaedic surgery, must accept the challenge, embedded in the 2004 presidential address of the Eastern Orthopaedic Association,43 to be a part of the solution to transforming institutions into professionalism-promoting organizations. A major way to do so is to contribute to improving our systems for assessment of professionalism and remediation of professional lapses. We must not be silent.

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In exploring our responses to professionalism of learners and colleagues in orthopaedic surgery, I suggested all too frequently we do not react; rather we are silent. I reviewed factors contributing to our silence. They include societal distaste of whistle blowers, institutional hierarchies that shift responsibility for identifying and correcting professional lapses to the upper levels of an organization, financial pressures that reduce faculty time for interacting with learners and each other, fear of retaliation, and the costs of litigation. Other barriers to assessment of professionalism and remediation of unprofessional behavior lie in the very nature of assessment and remediation and the beliefs we hold about them. As I indicated, assessment of professionalism requires that we examine the inner world of a human being while we prefer to deal with the outer, more objective, world. I noted that remediation can appear unduly intrusive, disrupt workflow, and have uncertain outcomes.

Yet, recent developments can reduce at least some of these obstacles. I described the most promising of these-models, principles, and programs that can advance the assessment of professionalism and remediation of professional lapses. These include longitudinal assessment programs that promote professional behavior, not just penalize lapses; transparency about the purposes of assessment; methods to separate formative from summative assessment; conceptual and behavioral definitions of professionalism codified into policy; techniques that increase the reliability and validity of quantitative and qualitative approaches to assessment such as 360-degree assessments, performance-based assessments, portfolios, and humanism connoisseurs; and systems-designs that provide infrastructure support for assessment. Models for remediation have been crafted; they include due process, a warning period, and if necessary confrontation to initiate remediation of the physician who has acted unprofessionally. Principles for appropriate remediation stress matching the intervention to the cause of the professional lapse. Cognitive behavioral therapy, motivational interviewing, and continuous monitoring linked to feedback and behavioral contracts are effective remediation methods.

However, I also argued that increasing the robustness of our assessment and remediation systems requires us to see medical education not only as a technical undertaking but also as a process promoting and maintaining the professional character of all participants. In turn, an institutional environment supportive of professionalism will facilitate the necessary changes in assessment and remediation systems to achieve the dual goal of medical education. We ourselves must live out our obligations to contribute to a positive institutional environment and to build appropriate systems for assessment of professionalism and remediation of unprofessional behavior of learners and colleagues.

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