Professionalism in medicine is taught - PowerPoint Presentation

Slide1

Professionalism in medicine is taught in the classroom to medical students during their preclinical years in an attempt to create and maintain a professional and ethical society of physicians. However, studies have shown that the ethical and professional qualities that students possess when entering medical school, and during their preclinical years, decline as they advance through their clinical training. What appears to be a likely etiology is the ‘hidden curriculum’ that exists in many training environments. Behaviors modeled by residents and faculty directly and powerfully teach medical students how they should act in order to be efficient members of a medical team. Unfortunately, these modeled behaviors include both professional and unprofessional behaviors.In order to improve an institution’s culture of professionalism, true change must penetrate all levels of the power hierarchy. While professionalism reporting by attendings or residents is likely unhindered, medical students are less likely to report residents or attendings who they witness behaving unprofessionally. Reasons for this lower rate of reporting are thought to stem from the intrinsic hierarchical nature of the medical team, fears of poor evaluations/grades or residency opportunities, concerns about disrupting team dynamics, or uncertainties about the seriousness of the unprofessional behavior. In an exit survey completed by the Baylor College of Medicine (BCM) Class of 2014, students’ reasons for non-reporting included fear of reprisal (31%), belief that nothing would be done about the concern (34%), and a sense that the concern was not important enough to report (66%). While the literature suggests some possible barriers to reporting, there are no published studies that investigate student perspectives on non-reporting or solutions to improve reporting. Mitigating the 'hidden curriculum' and genuinely allowing students to report freely without fear of retribution is essential if institutions desire to elevate their culture of professionalism. The present study is the first to appeal to a medical student body to evaluate the likelihood of, barriers to, and proposed strategies for improving medical student reporting of unprofessional behavior.

There were 272 respondents from the MS2-MS4 classes, for a response rate of 50.4%. RR by class was MS2 (42%), MS3 (68%), and MS4 (42%). 71% of students indicated they do not believe the administration will protect them from negative repercussions if they report unprofessional behavior. 87% of students report they are more likely to report unprofessional behavior that had multiple witnesses than behavior where they are the only witness. The top four barriers to reporting were: concern that reporting would create an awkward, uncomfortable, or hostile relationship (41%), preference for direct discussion of the professionalism violation with the individual involved, instead of formal reporting (23%), fear of a negative impact on grade, learning opportunity, research opportunity, or letter of recommendation (LOR) (23%), and uncertainty about the best way to report the violation (18%). The top three solutions/incentives were: implementing a system in which the release of reporting is delayed to a time specified by the student (37%), establishing a small group of medical students to serve as a triage committee that would advocate for the student and take the issue to the appropriate individuals (28%), and asking clerkship directors to look favorably on students who reported valid professionalism concerns when determining final grades (18%). Concern about the negative impact of reporting on grades or a LOR was lower for MS4s (18%) than for MS2 (26%) and MS3 (25%) classes. Development of a hostile/awkward relationship was a constant barrier as one moved from MS2 (39%) to MS3 (38%) to MS4 (39%) classes, while students were more likely to forgo reporting as they progressed in their clinical training (because doing so made them ‘feel like a valuable member of the team’), from MS2 (13%%) to MS4 (18%).

Review of student responses revealed the following: Persistent and significant amount of administrative distrust (about report follow-up & protections against repercussions) among students continues to cause apathy in reporting.Lack of clarity about what a professionalism violation entails.Preference for more formal measures in place to protect against repercussions.Ongoing confusion about the ‘best’ way to report.Desire for more transparency about the outcomes and consequences of reporting a professionalism violation.Desire for more follow-up after reporting, e.g. notification that administration or staff have taken action to address the reported incident.Desire for a reporting system that maintains student anonymity and/or allows for a timing delay in report release.Desire for a triage point person or committee (comprised of students) who can assess their concern and direct them to the proper member of the administration..

Non-reporting of professionalism violations continues to be a significant problem at Baylor College of Medicine. Cultural change must occur from the top down, starting with administrative leaders, and involve clinical clerkship directors and attending physicians. These members of the medical school community have the power to change institutional policies that better support student reporting of professionalism concerns, as well as to model professional behavior in clinical settings. Solutions only will lead to effective change if they are proposed by the student body and seriously implemented at a high level. When developing professionalism education programs, drafting institutional policies, and training faculty and staff, medical school administrators should give considerable weight to student-derived solutions that specifically address obstacles known to hinder reporting.

This project was funded by a grant from the BCM Center for Professionalism with the generous support of Dr. Ellen Friedman. We would also like to thank Dr. Anne Gill for her guidance and mentorship, and the BCM student body for their participation.

Joseph M. Armstrong, BA1, Rachel A. Taylor, BA1, Diana L. Whitney, BA1, Jaden R. Kohn, BS1, Anne Gill, Dr.PH1

1Baylor College of Medicine, Houston, TX

Between a rock and a hard place: Medical student perspectives on professionalism reporting

Identify the

significant barriers or obstacles that hinder student reporting of professionalism concerns?Identify possible solutions or incentives that would encourage students to report unprofessional behavior.Determine whether students’ willingness to report professionalism concerns declines as clinical training progresses.Investigate whether the perceived severity of a professionalism infraction impacts the likelihood of student reporting.

Feudtner

C, Christakis D, Christakis N. Do clinical clerks suffer ethical erosion? Studentsʼ perceptions of their ethical environment and personal development. Academic Medicine. 1994;69(8):670-9. doi:10.1097/00001888-199408000-00017.Brainard A, Brislen H. Viewpoint: Learning Professionalism: A View from the Trenches. Academic Medicine. 2007;82(11):1010-1014. doi:10.1097/01.acm.0000285343.95826.94.Reddy S, Farnan J, Yoon J et al. Third-Year Medical Students’ Participation in and Perceptions of Unprofessional Behaviors. Academic Medicine. 2007;82(Suppl):S35-S39. doi:10.1097/acm.0b013e3181405e1c.Dyrbye L, Massie F, Eacker A et al. Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students. JAMA. 2010;304(11):1173. doi:10.1001/jama.2010.1318.Hafferty F, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine. 1994;69(11):861-71. doi:10.1097/00001888-199411000-00001.Hafferty F. Beyond curriculum reform. Academic Medicine. 1998;73(4):403-7. doi:10.1097/00001888-199804000-00013.de Oliveira Vidal E, Silva V, Santos M, Jacinto A, Boas P, Fukushima F. Why Medical Schools Are Tolerant of Unethical Behavior. The Annals of Family Medicine. 2015;13(2):176-180. doi:10.1370/afm.1763.

INTRODUCTION

1

OBJECTIVES

METHODS

ACKNOWLEDGEMENTS

REFERENCES

RESULTS

Table 3:

Response Rate Class Response RateMS242.1% (N=78)MS367.8% (N=116)MS442.4% (N=78)TOTAL50.4% (N = 272)

Sample of free text answers:“This happens all the time, nothing will happen so it’s not worth it to report”We need “a reporting system that actually has follow-up”“Better patient care should be enough of an incentive (to report)”We need to “change the culture”“I think issues such as this are best handled, at least at first, by discussing the issue with the individual involved”We need a “clearer understanding of why [these are] reportable offenses”

CONCLUSION

RESULTS (CONTINUED)

Table 1: List of ‘representative’ professionalism violation scenarios

Scenario 1:

Your attending or resident comes to work dressed in a dirty white coat or with blood on their

scrubs.

*Scenario 2: Your attending or resident asks you to see a patient, then subsequently copies, pastes, and signs your note as their own note -- without seeing the patient.Scenario 3: In a crowded elevator, your attending or resident discusses a patient case using identifying patient information. Scenario 4: Your attending or resident makes derogatory remarks about patient(s). Scenario 5: Your attending or resident asks you to forge the attending's signature on a prescription for a controlled substance, in order to help clinic run more efficiently.Scenario 6: Your attending or resident comes to work under the influence of alcohol or drugs.**Scenario 7: Your attending or resident asks you to obtain informed consent on a patient who is about to undergo a procedure.

Table 2: Main survey formatQuestionAnswer Choice FormatHow likely are you to report this situation via any method?Sliding scaleWhat is the most significant reason or obstacle that prevents you from reporting this behavior?Multiple choice + free textWhat solution or incentive would encourage you to report this behavior?Multiple choice + free textHave you witnessed this clinical situation during your clinical training? Yes/No

*minor

infraction

control

** severe infraction control