Brought to you by the students of the University of Cincinnati College of Medicine
By Sam Kim
I wake up suddenly and I’m instantly anxious and worried. My cell phone, pulling double duty as my alarm clock, informs me plainly that it has failed in its latter duty. I am late for class.
At this point, you, dear reader, probably are scoffing. “So what, class is optional, what are you worried about?” I agree completely, there’s nothing to be worried about… unless today happens to be a mandatory session and I’ve missed it.
I’m pleased to report I have yet to miss a mandatory session but I am NOT a morning person and in the bleary-eyed dawn, I am never quite sure if I have to be in class or not. The case is something of a moot one since I generally go to class anyways but what’s all the hoopla about anyways? I’m worried about the dreaded professionalism letter which I am repeatedly threatened with via email and school policy. I’m not quite sure what this entails but it seems to me that it covers a lot of bases and can range from some things that are pretty severe to some that (arguably) are a bit trivial.
My other point of anxiety (trust me, coming from a guy who suffers from anxiety attacks, I really don’t need additional stressors beyond the significant ones presented by medical school curriculum) is the underlying insidious threat of missing a required block evaluation survey. Failure to do one of these friendly online surveys is also accompanied by the dark and shadowy threat of a professionalism letter.
While multiple occasions in the history of this school as well as other schools around the country have generated discussion around the topic of professionalism in medical school, I couldn’t help but think about the apparent disconnect I see in and out the hallowed halls of medical education. I won’t get into it, but in this day and age with Facebook, Twitter, and Google Groups, I couldn’t help but think that maybe this idea of professionalism was getting a little blown out of proportion. I wish I could say I found the data supported that suspicion – it doesn’t.
I’m not even going to touch the out of school setting and interactions with your non-medical peers. If you believe there’s merit to the adage, “Let he who hath no sin cast the first stone,” well let’s just say I certainly don’t have the right to warm up the deltoids and try out my throwing arm.
But what does it say when we are asked to be professional and yet we are persistently given the impression that we are under surveillance? I often get the feeling that venturing outside boundaries of a difficult-to-define term like “professionalism” will be instantly met with punishment. How can one be truly professional (i.e. motivated by a desire to be an expert in one’s field for purpose of just being better at one’s profession) and moved by a desire of positive self-improvement when the underlying motivation given to us by our institution is seemingly negative (punitive)? And moreover, does it matter what I do here in medical school? It doesn’t take long on a hospital floor to see and hear different attitudes about topics like beneficence, autonomy, justice, and non-maleficence. I can say those words and write the required reflections using those ‘power’ words but do these exercises reflect the reality of medicine?
- Does professionalism really matter?
A wealth of medical education research has been done on the topic of whether professionalism in medical school has a bearing on later performance as a practicing physician. Naturally, medical schools want to turn out physicians that are excellent and the best reflections of their respective medical school almae matres.
In a broad survey on the topic, I focused on four major studies referenced across multiple articles. The publications were all peer-reviewed journals including such best-sellers as the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA). In all the studies examined, a negative later performance was identified as disciplinary action from a state licensing board while identification of unprofessional behavior in medical was defined as something akin to our UCCOM professionalism letter.
Well, does it matter? The short answer is “yes.”
Across all the studies professionalism (or a lack or deficiency) was found to correlate to higher rates of later disciplinary action from a state licensing board. An in-depth statistical analysis of retrospective case studies at medical education institutions including the University of California at San Francisco, the University of Michigan, Jefferson Medical College at the University of Philadelphia revealed surprising results. By defining certain categories of “unprofessionalism,” researchers were able to calculate and quantify sets of risk ratios. One study published in the NEJM found that, in general, “physicians who were disciplined by state medical-licensing boards were three times as likely to have displayed unprofessional behavior in medical school than were control students.” (Papadakis et al, 2004)
The clinical years have a wide base of support in predicting later physician-appropriate behavior but these days, the current debate borders around whether the same weight should be given to 1st and 2nd year student behavior as well. (Papadakis MA, Loeser H, 2001)
- What is considered “unprofessional behavior?”
While the various studies use slightly different terminology, three categories yield the most significant correlations. These categories included exhibiting a lack or deficiency in:
2. Self-improvement/Ability to Receive Criticism
A study (again from UCSF, they seem to be really into this stuff) published in JAMA found that among 68 case (disciplined) and 196 matched controls (non-disciplined) physicians, the three categories in medical school bore statistical significance in predicting future disciplinary action by state medical licensing boards. (Teherani A, 2005) Of most concern (in a separate study looking at data from 40 state licensing boards), those students who were “most irresponsible” had a risk eight times that of controls while those “most resistant to self-improvement” exhibited a risk three times as high. (Papadakis MA et al, 2005)
Consider how you present yourself now. It turns out professionalism as an underclassman predicts your behavior later even before you leave medical school. One study found that medical students lacking “thoroughness” and an “inability to perceive weaknesses” in the first and second years of medical school were more likely to later exhibit unprofessional behaviors in the clinical setting (i.e. M3/M4 years). (Stern DT et al, 2005) Similar findings at the University of New Mexico corroborated the importance of assessing professionalism in the first two years of medical school and a real need to address early deficiencies. (Phelan S, 1993)
Disciplinary action from a state licensing board is a big deal and not merely a common occurrence. To put that statement in perspective, the 2003 national rate of disciplinary action among about 725,000 physicians hovers at 0.3 percent. (Summary of 2003 Board Actions (fsmb.org), 2004) So it’s best for medical schools to identify and try to address predictive factors now. Between you and me, I think that scenario is actually better for both parties: a professionalism letter and a discussion with your dean – as bad as that may sound – is a whole lot better than the ‘adult’ equivalent in front of a state licensing board.
- Where is the unprofessionalism coming from?
Unless you follow the teachings of the shadier Philosophes (Thomas Hobbes believed human nature was inherently evil, I’m more of a Rousseau guy myself), most medical students got into this gig because they wanted to help people.
So how do these high-minded morals become corrupted? The answer to this question is complicated and unclear but there are a few points to consider. Hafferty conducted multiple studies showing that the “informal” and “hidden” curricula (i.e. the ‘unspoken’ lessons learned from mentors/physicians/peers about the ‘real world’) more strongly influences the interpersonal behavior and culture than the formal curricula that it often directly opposes. (Hafferty FW, 1994) (Hafferty FW, 1998)
Adding weight to that assertion, students surveyed from no less than six medical schools reported hearing instructing physicians refer to patients in a “derogatory manner” while on wards (98%) and witnessing team members engage in behavior the students considered “unethical" (61%) . (Feudtner C, Christakis DA, 1994)
Even worse, multiple opinions among prominent medical educators and researchers widely agree that professionalism, while almost unanimously seen crucial in the development of the medical skill set, is not rewarded or properly weighted. Many evaluations on professionalism are considered to be unreliable either due to a lack of specific feedback or what is termed the “leniency error.” (Kreiter et al, 1998) (Littlefield et al, 1997) One paper went so far as to characterize such assessments as being “little more than a popularity contest.” (Cunnington et al, 1997)
School administrations seem to be a bit unsure on the topic as well. Kao, Spevick, and Barzansky published findings in JAMA that discovered among a study of associate deans responsible for medical schools’ curricula, 97% of them were requesting faculty development materials. (Kao et al, 2003) In addition, many faculty members felt either they were ill-equipped or unable to assess measures such as professionalism or provide adequate feedback to students. (Richards et al, 1999) (Hewson et al, 2000)
- Well, damn. What are you saying anyways?
The good news is that many of the above-mentioned data have already been considered and the struggle to adequately address these issues is ongoing but progressive. Researchers generally suggested including such improvements as:
• Increased direct observation in the earlier years (Long-Term Primary Care Clerkship, LPCC)
• Classes directly addressing professionalism (Physician and Society)
• Clearly defined systems for identifying and addressing incidents of unprofessional behavior
• Increased exercises involving Standardized Patient Interaction (Clinical Skills)
However there is still a great deal of room for improvement and though these measures were espoused by many of the authors, several lacked the concrete articulation that medical students often seek when looking to emulate or adhere to behavior (So what exactly can I do? What can I definitely NOT do?). And while the insidious and corruptive nature of the “informal and hidden” curriculum was identified way back in 1994, I think both you and I can agree it is still present, alive, and thriving.
Here’s the problem: grades and reports reflecting professionalism are not held in equal esteem as the grades based on memorization, quizzes, and block exams. That inequality is just as much placed (some would argue, if not more) on the shoulders of the administration, medical community, and even your favorite TV medical drama as it is on we students. Until positive reinforcement about professional conduct is rewarded in equal value as board scores and test grades in the form of favorable residencies, positions, and consideration by our peers and patients, the sticky issue of professionalism and what to do with it will persist.
I don’t really know what to make of everything. If anything, I went into this investigation thinking such measures of professionalism in medical school would find specious, marginal, or even meaningless connections between professionalism and later disciplinary action as a doctor. You can see that wasn’t the case. However, as with any research findings, we should consider sources of bias and admit that most of these researchers would probably benefit from such conclusions. It’d be hard to argue that a professionally-minded medical student would be harder to deal with from the perspective of administration.
But in the end, I choose to look for the positives in the drudgery of all this data. While I’m definitely not perfect, if there’s a real connection between my behavior and attitude today, I am going to at least try to be more cognizant of how professionally I conduct myself at school.
I was really interested that M1s and M2s that didn’t identify their weaknesses were likely to exhibit unprofessional behavior in the 3rd and 4th years. So with that point in mind, I will resolve to be more candid about when I don’t know things, when I need help, and attempt to solicit and appropriately respond to constructive criticism. I’ll try to worry less about whether I’m just a whole lot dumber than my classmates. I’m betting that the chances are that being open and earnest with your peers will not only show we’re more alike than different but also identify more than a few readily-offered helping hands.
Recent studies in mood disorders have shown that even pretending to be happy can have a positive impact on psychiatric wellbeing. In other words, even if you know you’re ‘faking it,’ it’ll eventually start to change you. Depression patients get a little happier when playing the part even when they’re in on the gig. Maybe professionalism works the same way since it has to do with how our brains work too and the research backs it up. This investigation identified no less than five papers that posit professionalism can be not only taught but also learned. So even if the session on ethics seems pointless and the principles of autonomy, beneficence, justice, and non-maleficence are just words used in medical school - play along. It matters.
If you are what you eat, perhaps the way you act professionally today is the kind of doctor you’ll become tomorrow.
- Some interesting things I discovered in research but didn’t really seem to find a place for it in the article (Papadakis et al, 2005)
• Despite popular conception and earlier studies, gender is not a meaningful determinant of either unprofessional behavior or later disciplinary action as a physician. Males are neither more nor less likely than females to be brought before a state licensing board for professional misconduct.
• While OB/GYN, general practice, psychiatry, and family medicine doctors were more likely to be disciplined, pediatricians and radiologists were less likely to receive disciplinary action.
• The specialties of internal medicine, surgery, and anesthesiology were found to be neither more nor less likely to be disciplined.
• Students with low grades in the first two years of medical school (defined as failing one or more classes) were found to be about a quarter more likely to be disciplined. Low MCAT scores were found to be similarly predictive.
• Physicians who are in practice for more than 20 years are at increased risk for disciplinary action. (Hurray for older medical students! Finally, an [small] upside to graduating later)
Sam Kim is a newly-minted second year medical student at UCCOM and less than newly-minted human being in his late-twenties He hopes to finish his second year with the promise of a third and perhaps even a fourth. Professionalism letters, disciplinary action from medical licensing boards, and brevity-in-prose are not among the interests listed on his Facebook profile.
Does professionalism in medical school really matter? Is it predictive?
Copyright © 2012 Mentis
About the Author:
Sam Kim is a second-year medical student