There is little debate that over the last two decades an increased amount of attention has been paid to teaching professionalism to medical students and resident physicians.
But that trend has only added to the complexities of professionalism – what it is and how best to define it. And, at the same time, there has been little attention focused on the development of practical strategies for remediating unprofessional behavior.
Now, in a research article published this week in the New England Journal of Medicine, “Responding to Unprofessional Behavior by Trainees – A ‘Just Culture’ Framework,” two professors from WMed and a professor from Oakland University William Beaumont School of Medicine have put forth what they believe – and hope – could become the “gold standard” for professionalism remediation in undergraduate and graduate medical education.
“We believe that lapses in professional behavior can be addressed productively if we view them through the lens of medical error, drawing on ‘just culture’ principles and related procedural approaches,” Tyler Gibb, JD, PhD, and Michael Redinger, MD, co-chiefs of the medical school’s Program in Medical Ethics, Humanities, and Law, said in the piece along with lead author Jason A. Wasserman, PhD, associate professor in the Department of Foundational Medical Studies at Oakland University William Beaumont School of Medicine.
“Repurposing these concepts can help medical educators promote a formative learning environment while fairly and rigorously addressing problematic behaviors.”
The Just Culture Approach put forth by Drs. Gibb, Redinger, and Wasserman involves the creation of a “culture of psychological safety” that gives way to open dialogue, dissent and transparent reporting with a focus on balancing individual and system accountability. Drawing on those principles, the approach recognizes not only what happened in any particular instance, but the knowledge and intentions of the student, as well as the contributions of the learning environment itself.
“We can adapt strategies to address medical errors in a parallel way for lapses in professionalism,” they said. “Our approach to evaluating and remediating lapses in professionalism achieves several goals. It is broadly applicable to situations in which expectations of professional behavior are not met. It is grounded in shared values of medical educators … It distinguishes helpfully among kinds of lapses on the basis of relevant factors, including the trainee’s knowledge of expectations, intentions, and foreseen consequences, and the influence of confounding systemic factors.”
At WMed, the undergraduate curriculum is centered around eight domains, one of which is professionalism. Graduate medical education also includes professionalism as one of the six ACGME core competencies. Dr. Hal B. Jenson, the medical school’s founding dean, said professionalism is intentionally “hard-wired” into the curriculum.
“How you do things is just as important as what you do. We have high expectations for professionalism for our students and residents from the time they arrive here,” Dr. Jenson said. “Having faculty like Drs. Gibb and Redinger here brings an added dimension to our education that goes beyond the science of medicine to the art of medicine and how we practice medicine.”
Dr. Redinger said the research article, which was submitted to the New England Journal of Medicine in late 2019, was the result of a collaboration that began while he and Dr. Gibb, along with Dr. Wasserman, were attending the same ethics conferences. They quickly realized that their philosophies – specifically on how to deal with professionalism lapses by students and residents – were similar and successful.
“We would bounce ideas off one another about how we handled specific situations and we found that we had really similar ways of thinking about it and they were ways that weren’t reflected in current best practices in the literature, but we were having some success,” Dr Redinger said. “We realized that the medical error model could be adapted to these situations with students and residents. A lot of times they are in situations that have other systemic factors that are playing a role in how they make a decision or how they decide to do something or not to do something.”
Dr. Redinger and Dr. Gibb said they are excited that their work with Dr. Wasserman is now a part of the New England Journal of Medicine, which is the oldest – and among the most prestigious – peer-reviewed medical journals.
“For me, so much of what we do is pretty specific and esoteric, and even if it’s high-quality stuff the ability to impact our peers and the profession of medicine is relatively limited,” Dr. Gibb said. “But this article being published in this venue has the opportunity to be read by vastly more people. It’s a different magnitude of impact.”
In the piece for the New England Journal of Medicine, Drs. Gibb, Redinger and Wasserman write that “professionalism is not only a matter of individual character or action, but simultaneously a function of systemic factors in the learning environment. It traverses the formal curriculum and spills into our hallways, cafeterias, lounges, and offices.”
Given that reality, Dr. Redinger the framework for professionalism remediation he and Drs. Gibb and Wasserman present in the research article is intentional about the importance of early intervention for medical students and residents. That early intervention is meant to stem the risk of serious issues in the future, such as medical license revocation or malpractice lawsuits, that can often be connected back to a physician’s issues with professionalism as a medical student or resident physician.
“We’re hoping this becomes the pre-imminent model that’s adopted by other medical schools for dealing with these sorts of issues,” Dr. Redinger said. “The one thing that is really damaging to the medical profession as a whole are professionalism lapses. The bad actions of individuals have ramifications for everyone else in the medical profession.
“So, as a result, we have to focus on those individuals that are struggling,” Dr. Redinger added. “If we’re not paying special attention to the medical students and residents struggling at the outset, they may get left behind and that puts them at risk. It puts patients at risk.”