Unprofessional behavior by specialty: a qualitative analysis of six years of student perceptions of medical school faculty

Is insufficient introspection a reason to terminate residency training? - Scrutinising introspection among residents who disputed dismissal

INTRODUCTION

Insufficient introspection as part of the 4I's model of medical professionalism (introspection, integrity, interaction, and involvement) is considered an important impediment in trainees. How insufficient introspection relates to decisions to terminate residency training remains unclear. Insights into this subject provide opportunities to improve the training of medical professionals.

METHODS

We analysed the Dutch Conciliation Board decisions regarding residents dismissed from training between 2011 and 2020. We selected the decisions on residents deemed 'insufficient' regarding introspection as part of the CanMEDS professional domain and compared their characteristics with the decisions about residents without reported insufficiencies on introspection.

RESULTS

Of the 120 decisions, 86 dismissed residents were unable to fulfil the requirements of the CanMEDS professional domain. Insufficient introspection was the most prominent insufficiency (73/86). These 73 decisions described more residents' insufficiencies in CanMEDS competency domains compared to the rest of the decisions (3.8 vs. 2.7 p < 0.001), without significant differences regarding gender or years of training.

CONCLUSIONS

Insufficient introspection in residents correlates with competency shortcomings programme directors reported in dismissal disputes. The 4I's model facilitates recognition and description of unprofessional behaviours, opening avenues for assessing and developing residents' introspection, but further research is needed for effective implementation in medical education.

What we think about professional and unprofessional behaviors: differences between the perception of clinical faculty members and medical students

INTRODUCTION

Differences in the viewpoints of clinical faculty members and medical students about prioritizing professional norms accepted by the professional community and lack of alignment of these views can lead to distortion of understanding, problems in learning and assessment of professionalism, and failure in students' professional identity formation. This study aimed to identify the differences in viewpoints of clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors among undergraduate medical students.

METHODS

A multi-stage qualitative study was conducted at Tehran University of Medical Sciences during 2020-2021. At first, a systematic search was conducted to identify professional and unprofessional behaviors using the directional content analysis method. A panel of experts was formed to check the codes obtained from reviewing the literature and to evaluate its compliance with the context. Then, the modified nominal group technique sessions were held with clinical faculty members and medical students to strengthen the codes extracted from the studies and systematically integrate their views to achieve a comprehensive list of professional and unprofessional behaviors in accordance with the context. Finally, a consensus was made among them about prioritizing the importance and prevalence of these behaviors in undergraduate medical students.

RESULTS

A total of 490 codes of professional behaviors and 595 unprofessional behavior codes were identified in the literature review. In the following sessions of the modified nominal group, 13 clinical faculty members listed 105 codes of professional and unprofessional behaviors, and 51 medical students also listed 313 codes. The results of the modified nominal group technique showed that the faculty members reported the importance of unprofessional behaviors higher than professional ones. At the same time, students rated the importance of professional behaviors higher than unprofessional ones. Both faculty members and students rate the prevalence of professional behaviors as high and the prevalence of unprofessional behaviors as low.

CONCLUSION

The results showed a difference of views between clinical faculty members and medical students about prioritizing professional and unprofessional behaviors. It is essential to align their viewpoints to understand, learn and value professionalism to develop a professional identity.

Residents' Experiences of Negative Emotions toward Patients: Challenges to their Identities

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians - wanting respect and specific unexpected patient behaviors; learners - desiring complete autonomy and experiencing challenges with attending physicians; teachers - wanting to be a role model and protect junior learners; and workers - trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies.

Human factors affecting intraoperative patient safety

PURPOSE OF REVIEW

This review addresses the importance of some of the human factors for intraoperative patient safety with particular focus on the active failures. These are the mishaps or sentinel events related to decisons taken and actions performed by the individual at the delivery end of a system. Such sentinel events may greatly affect intraoperative patient safety.

RECENT FINDINGS

Intimidating, aggressive and disruptive communication is a cause of adverse staff interaction, which may then represent an important patient safety threat. Also, anaesthesiologist's physical and mental state and limitations may interfere with patient safety.

SUMMARY

The concept of physician well being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Creating optimal safe conditions for patients, therefore, requires actions at both the personal level and the working conditions. Also, initiatives to ban rude and dismissive communication should be implemented in order to further improve intraoperative patient safety.

Medical students' reflections on surgical educators' professionalism: Contextual nuances in the hidden curriculum

INTRODUCTION

Surgical educators' professional behavior constitutes a hidden curriculum and impacts trainee's professional identity formation. This study explores the nuances of professional behaviors as observed in varying surgical settings.

METHODS

411 Transcripts originated from essays written by MS3 students during their surgical clerkship from 2010 to 2016 were collated. Employing a qualitative research methodology, we conducted a thematic analysis to uncover specific meaning emerging from medical student reflections' on surgical professionalism.

RESULTS

In clinics, taking time and protecting patient privacy; in the OR, control over emotion during difficult situations and attention to learners; and in the inpatient setting, showing accountability above normal expected behavior were noted as professional. Similarly, unprofessional behaviors in these contexts paralleled lack of these attributes.

CONCLUSIONS

Behaviors observed and the attributes of professionalism in the surgical learning environment have contextual nuances. These variations in professionalism can be utilized in deliberate development of professionalism in surgery.

Assessing Professionalism in Medicine - A Scoping Review of Assessment Tools from 1990 to 2018

BACKGROUND

Medical professionalism enhances doctor-patient relationships and advances patient-centric care. However, despite its pivotal role, the concept of medical professionalism remains diversely understood, taught and thus poorly assessed with Singapore lacking a linguistically sensitive, context specific and culturally appropriate assessment tool. A scoping review of assessments of professionalism in medicine was thus carried out to better guide its understanding.

METHODS

Arksey and O'Malley's (2005) approach to scoping reviews was used to identify appropriate publications featured in four databases published between 1 January 1990 and 31 December 2018. Seven members of the research team employed thematic analysis to evaluate the selected articles.

RESULTS

3799 abstracts were identified, 138 full-text articles reviewed and 74 studies included. The two themes identified were the context-specific nature of assessments and competency-based stages in medical professionalism.

CONCLUSIONS

Prevailing assessments of professionalism in medicine must contend with differences in setting, context and levels of professional development as these explicate variances found in existing assessment criteria and approaches. However, acknowledging the significance of context-specific competency-based stages in medical professionalism will allow the forwarding of guiding principles to aid the design of a culturally-sensitive and practical approach to assessing professionalism.

Beyond mistreatment: Learner neglect in the clinical teaching environment

Medical student mistreatment has been recognized as a deterrent to education as it interferes with the learning process and contributes to student burnout and attrition. Medical schools and leaders in undergraduate medical education have expended tremendous effort in addressing this phenomenon in hopes of eradicating mistreatment. However, there is a spectrum of behaviors that negatively impact the learning environment beyond that which is considered frank mistreatment. In this conceptual article, the authors propose the concept of learner neglect for the consideration by educators and researchers. This is a term for a range of behaviors exhibited intentionally or unintentionally by a supervisor that prevent a learner from reaching his or her potential. While the behaviors may overlap with mistreatment, they do not always fit within the definition of mistreatment. This concept is illustrated in the context of optimal and suboptimal teaching behaviors that commonly occur within the ecosystem of clinical education. Descriptions and examples are provided for both intentional and unintentional learner neglect. The authors hypothesize possible short- and long-term impacts of learner neglect, describe contributors to its prevalence, and offer questions for key stakeholders to consider in an effort to recognize, study, and ameliorate this issue within medical education programs.

Golden Age of Medicine 2.0: Lifestyle Medicine and Planetary Health Prioritized

The 'golden age of medicine' - the first half of the 20th century, reaching its zenith with Jonas Salk's 1955 polio vaccine - was a time of profound advances in surgical techniques, immunization, drug discovery, and the control of infectious disease; however, when the burden of disease shifted to lifestyle-driven, chronic, non-communicable diseases, the golden era slipped away. Although modifiable lifestyle practices now account for some 80% of premature mortality, medicine remains loathe to embrace lifestyle interventions as medicine Here, we argue that a 21st century golden age of medicine can be realized; the path to this era requires a transformation of medical school recruitment and training in ways that prioritize a broad view of lifestyle medicine. Moving beyond the basic principles of modifiable lifestyle practices as therapeutic interventions, each person/community should be viewed as a biological manifestation of accumulated experiences (and choices) made within the dynamic social, political, economic and cultural ecosystems that comprise their total life history. This requires an understanding that powerful forces operate within these ecosystems; marketing and neoliberal forces push an exclusive 'personal responsibility' view of health - blaming the individual, and deflecting from the large-scale influences that maintain health inequalities and threaten planetary health. The latter term denotes the interconnections between the sustainable vitality of person and place at all scales. We emphasize that barriers to planetary health and the clinical application of lifestyle medicine - including authoritarianism and social dominance orientation - are maintaining an unhealthy status quo.

Bad manners in the Emergency Department: Incivility among doctors

Introduction

Negative workplace behaviour, especially negative communication is a recognised problem in many organisations and is known to have serious impact on workplace performance, productivity and personal wellbeing. Emergency Departments (ED) can be high stress environments in which communication and perceptions of respect between physicians and other staff may underlie individual functioning. We conducted a study to estimate the influence of incivility (ICV) among physicians in the ED.

Methods

We developed an online survey to assess workplace incivility in the ED. We focussed on frequency, origin, reasons and situations where ICV was reported. To measure the levels and the potential influence of ICV on psychological safety, social stress and personal wellbeing we correlated our questionnaire to standard psychological scales. Statistical analysis included Students t-test, chi squared distribution and Pearson correlation coefficient.

Results

We invited all seventy-seven ED physicians to participate in our survey. Among those that completed (n = 50, 65%) the survey, 9% of ED physicians reported frequent (1/week) and 38% occasional (1/month) incidents of ICV. 28% of physicians reported experiencing ICV once per quarter and 21% reported a frequency of only once per year, no physician reported ICV on a daily basis. Levels of ICV were significantly higher in interactions with specialists from outside then within the ED (p<0.01).

ICV was perceived particularly during critical situations. Our findings showed a significant correlation between internal (within the ED team) ICV and psychological safety. To ED physicians internal ICV was associated with lower levels of psychological safety (p<0.01). ICV displayed from sources outside the ED team was not associated with psychological safety, but we found a significant influence of external ICV on personal irritability and reduced wellbeing (p<0.01).

Discussion

The incidence of incivility was high among the ED physicians. Although this was a small sample, the association between workplace ICV and psychological safety, personal irritation as well personal comfort suggests that ICV may be an important variable underlying ED team performance. These findings further underscore the need to foster a culture of respect and good communication between departments, as levels of ICV were highest with physicians from outside the ED. Future research would benefit from examining strategies to prevent and reduce ICV and identify reasons for personal variation in perception of ICV. During critical situations and in general collaboration with specialists, awareness of ICV and countermeasures are important to avoid decreased performance and negative impact on staff and patient.

Self vs. Other Focus: Predicting Professionalism Remediation of Emergency Medicine Residents

Introduction

Unprofessionalism is a major reason for resident dismissal from training. Because of the high stakes involved, residents and educators alike would benefit from information predicting whether they might experience challenges related to this competency. Our objective was to correlate the outcome of professionalism-related remedial actions during residency with the predictor variable of resident response to a standardized interview question: “Why is Medicine important to you?”

Methods

We conducted a professional development quality improvement (QI) initiative to improve resident education and mentorship by achieving a better understanding of each resident’s reasons for valuing a career in medicine. This initiative entailed an interview administered to each resident beginning emergency medicine training at San Antonio Military Medical Center during 2006–2013. The interviews uniformly began with the standardized question “Why is Medicine important to you?” The residency program director documented a free-text summary of each response to this question, the accuracy of which was confirmed by the resident. We analyzed the text of each resident’s response after a review of the QI data suggested an association between responses and professionalism actions (retrospective cohort design). Two associate investigators blinded to all interview data, remedial actions, and resident identities categorized each text response as either self-focused (e.g., “I enjoy the challenge”) or other-focused (e.g., “I enjoy helping patients”). Additional de-identified data collected included demographics, and expressed personal importance of politics and religion. The primary outcome was a Clinical Competency Committee professionalism remedial action.

Results

Of 114 physicians starting residency during 2006–2013, 106 (93.0%) completed the interview. There was good inter-rater reliability in associate investigator categorization of resident responses as either self-focused or other-focused (kappa coefficient 0.85). Thirteen of 50 residents (26.0%) expressed self-focus versus three of 54 (5.4%) residents expressed other-focus experienced professionalism remedial actions (p<0.01). This association held in a logistic regression model controlling for measured confounders (p=0.02).

Conclusion

Self-focused responses to the question “Why is Medicine important to you?” correlated with professionalism remedial actions during residency.

Sticks and stones: investigating rude, dismissive and aggressive communication between doctors

Destructive communication is a problem within the NHS; however previous research has focused on bullying. Rude, dismissive and aggressive (RDA) communication between doctors is a more widespread problem and underinvestigated. We conducted a mixed method study combining a survey and focus groups to describe the extent of RDA communication between doctors, its context and subsequent impact. In total, 606 doctors were surveyed across three teaching hospitals in England. Two structured focus groups were held with doctors at one teaching hospital. 31% of doctors described being subject to RDA communication multiple times per week or more often, with junior and registrar doctors affected twice as often as consultants. Rudeness was more commonly experienced from specific specialties: radiology, general surgery, neurosurgery and cardiology. 40% of respondents described that RDA moderately or severely affected their working day. The context for RDA communication was described in five themes: workload, lack of support, patient safety, hierarchy and culture. Impact of RDA communication was described as personal, including emotional distress and substance abuse, and professional, including demotivation. RDA communication between doctors is a widespread and damaging behaviour, occurring in contexts common in healthcare. Recognition of the impact on doctors and potentially patients is key to change.

Rasch analysis of professional behavior in medical education

The use of students' "consumer feedback" to assess faculty behavior and improve the process of medical education is a significant challenge. We used quantitative Rasch measurement to analyze pre-categorized student comments listed by 385 graduating medical students. We found that students differed little with respect to the number of comments they provided and that their comments indeed form a probabilistic Rasch hierarchy. However, different hierarchies were found across medical departments and faculty. An analysis of these interactions provides valuable, detailed, and quantitative information that can augment qualitative research approaches. In addition, we suggest how the Rasch scaling of student comments can assist researchers in the design and implementation of new faculty evaluation instruments. Finally, the interactions between student and department identified a subset of behaviors that appear to guide and possibly elicit students' comments.