Chapter 9: When a Learner Is Not Meeting Expectations Relating to Professionalism

Chapter Authors: Debra Boyer, MD & Suzanne K. Woods, MD

The majority of learners will have no issues with passage through the developmental stages of professional competency. They will move from being medical students, whose course of learning and behavior were guided by others, to a mode of learning and professional behavior that is self-directed as graduate medical education trainees. Occasionally, there will be a learner who needs extra guidance and perhaps even external control. Rarely, one may encounter an individual who is not suited for a professional career in pediatrics and who has escaped the normal processes in place to protect patients and the public at large. These are the most challenging situations for a program director. They are fraught with interpersonal stress, institutional and program upheaval, and occasionally legal entanglements. When unprofessional behavior occurs, it is the responsibility of the program director to determine the weight of the infraction and to chart a course of action. What follows in this chapter are some suggested guidelines for addressing remediation in professionalism.

It is critically important to identify deficiencies in training and to immediately embark on a remediation action plan.  Lapses in professionalism can be in different categories and include behavioral, performance, attitude or accountability issues.¹ It is imperative for the program director to have accurate and extensive documentation related to professionalism issues. The program director must document the assessments that identified the professionalism deficiency, and all conversations, meetings, and actions involved in the development of a plan. This documentation should be placed in a separate and non-discoverable file. If further action is needed by the program, institution or outside agencies, the program director will need to have this record in place. There may be future inquiries regarding whether the learner ever had a break in training or any unusual monitoring. These questions often appear on credentialing and licensing forms. The proper answer to these questions depends on the severity of the professional lapse. A single lapse could be considered part of a learners' developmental process, but learners should be aware that serious professional problems will require a notation on future credentialing forms. Program directors are encouraged to meet with a trainee who is having trouble in the presence of a third party, such as a chief resident/fellow, assistant program director or other faculty member to provide a witness about what was communicated.

Lapses in professional behavior are often the result of stress, anxiety, depression, and exhaustion. These are the enemies of professional conduct, and someone who is generally functioning well may lapse because of such external forces. The program director’s first course of action may be to try to identify any of the aforementioned conditions and to see if they can be alleviated or diminished. Counseling by a mental health professional may be very helpful in returning a learner to his/her baseline of professional behavior. Guidance should be offered by the program director, but counseling should be left to a qualified external professional.

Developing a Remediation Plan

When a program director determines that a learner requires remediation for a lapse in professionalism, a careful plan for remediation and follow-up must be developed.  In general, a program director must decide whether to pursue broad remediation with activities directed towards professionalism issues in general.  Or, one may choose to focus on the specific behaviors in which the learner has demonstrated lapses.  This decision will help guide the remediation plan. 
 
It is challenging to find literature on best practices for remediation of graduate medical education trainees with respect to deficiencies in professionalism.  Authors have noted that the assessment methods used by program directors for identifying deficiencies in competence and the strategies used to remediate these challenges are not standardized.² The Alpha Omega Alpha Medical Honor Society has developed a publication on Best Practices in Medical Professionalism that program directors may find extremely useful.  In this document, a format for developing a remediation plan is proposed that includes the following:³

1. Assessment/Diagnosis of the problem
2. Development of an individualized learning plan
3. Perform instruction and remediation activities
4. Follow-up and reassessment with the learner/certification of competence

The first step in the remediation plan includes identification of the deficiency through the assessment process utilized by the training program. Ideally, multiple reliable and valid assessment tools are utilized to uncover the deficiency as it may cross domains of competence.  The second step involves having an organized approach to the learner’s lapse in professionalism and the creation of a specific plan tailored to the deficiency of the individual.  Once the lapse is confirmed, it is critical to understand the context in which it occurred and communicate a clear action plan to the learner. This written document articulating the action plan should include characterization of the professionalism lapse, the clear requirements for remediation including specific behavioral change goals, the plan for monitoring and reassessment, guided self-reflection and/or deliberate mentored practice, if recommended, feedback during the remediation process, expectation for what is acceptable performance and a clear outline of the consequences.  Guidance and mentorship is critical in the implementation and successful completion of a remediation plan.  The third step involves the provision of the remediation activities and consideration of services the learner may need both personally and professionally. Behavioral approaches may need to be considered when dealing with breaches of professionalism. The final component of the plan includes reassessment to ensure that the learner has achieved an acceptable level of performance. It should be noted that depending on the guidelines of the institution, other supervisors such as the Department Chair, Vice Chair of Education, the Designated Institutional Office or others, may need to be notified of such trainee issues. 
 
A number of institutions have developed formal remediation programs to work with trainees and physicians with professionalism lapses.  These include the Vanderbilt model, the Center for Professionalism and Peer Support at Brigham and Women’s Hospital and the University of Colorado School of Medicine Remediation Program.  Each of these programs differ in their focus and intensity.   The Vanderbilt model is tiered, with interventions dependent on the degree of the infractions.⁴  Similarly, the Brigham and Women’s Hospital program is a multi-step process with an emphasis on changing the unwanted behavior.⁵  Finally, the University of Colorado School of Medicine program works with trainees both with medical knowledge and clinical reasoning deficits as well as professionalism issues.⁶  Through the development of a Success Team, this program develops a comprehensive remediation program.⁶

Whether your institution has a formal remediation program, such as is described above, or you need to create one independently, it is critical to follow the four steps noted above.  Enlist the aid of those at your institution with experience in the remediation process and document your process all along the way.  In most instances, the program director and the learner should establish a contractual remediation plan. Such a plan would specify tasks or criteria that the learner must fulfill before returning to a position of good standing within the program.

Leave of Absence

At times it may be necessary to recommend or, even require, a leave of absence for an individual learner. When behaviors fall to a level that may be harmful to the trainee or potentially to a patient in the trainee’s care, a leave should be required. There should be program and institutional guidelines in place that give the program director authority to take this action. This will ensure that the trainee seeks the kind of help that he/she needs in order to return safely to work.

What Constitutes Egregious Action

• Willful misrepresentation of clinical data
• Providing care while under the influence of alcohol or drugs
• Involvement in illegal activity
• Physical or verbal abuse directed toward patients, families, colleagues, or staff
• Sexual misconduct or violation of appropriate physician-patient boundaries
• Humiliation or harassment
• Prejudicial behavior
• Failing to notify supervisors of inability to work
• Falsification of research data
• Failure to disclose ties to industry
• Coercion of a patient to join a research study

Consideration of Context and Pattern of Behavior

It may be appropriate to consider the context in which unprofessional behavior occurs and whether the lapse is a single event or a pattern of behavior. There is clearly a gradation in the seriousness of offenses. Consideration can be given to the meaning of an episode for the individual learner and the program but the program must articulate what constitutes acceptable and clearly unacceptable behaviors.

When Context Does Not Matter

There will be some instances in which legal and ethical standards have been breached requiring that action be taken regardless of context or pattern of behavior. Such acts might include physical assault, sexual misconduct, and wanton harm of patients or their families.

Specific tools available to help with breaches of legal/ethical standards

• Consultation
  • In these difficult situations, the program director should request consultation from departmental and hospital administrative staff. In many cases, the hospital attorney will need to be informed and consulted. Hospitals may have ethics boards, graduate medical education committees or other constituents of a due process procedure.
• Documentation
  • In more egregious cases of professional misconduct that may result in criminal or civil litigation, an even higher standard of documentation is required. The graduate medical education office at your institution can help you define what is necessary.
• Physician Impairment Program
  • In many states, there are specific physician impairment programs, particularly for cases of substance abuse. These programs are very helpful in providing sufficiently rigorous surveillance and specific referral resources to avoid loss of license and/or board certification.
• Involvement of Law Enforcement
  • In some cases, the hospital may choose to notify law enforcement officials about specific violations of criminal law such as assault, robbery, or drug sales.
• Notification of the American Board of Pediatrics
  • A program director has the responsibility to notify the ABP if a lack of professionalism has been identified during training that warrants further evaluation and observation, or an extension of training. Although reporting may occur at any time, the ABP requires program directors to evaluate the clinical competence and professionalism of residents at the end of each year of training on the tracking roster. The critical elements for a program director to understand include:
    • If an unsatisfactory evaluation is given for professionalism, the resident must repeat the year of training or, at the discretion of the ABP and recommendation by the program director, complete a period of observation.  Until the unsatisfactory evaluation is remediated, the Board will withhold permission to take the certifying examination.
    • A resident or fellow who receives an unsatisfactory evaluation for professionalism receives no credit for that year of training, unless the program director provides evidence as to why a period of observation would be more appropriate than a repeat year of training.
    • If a period of observation is acceptable and the resident is at the end of his/her training period, this observation will extend into a subsequent training period, such as during a subspecialty fellowship or during a physician’s initial period in practice.
    • A plan for remediation must be developed and submitted to the ABP for approval. Observation plans for lapses in professionalism are developed on a case-by-case basis. The observer must provide an assessment of clinical competence with particular attention to professional attitude and behavior at the end of the agreed upon period of observation.
    • Less than satisfactory performance in professionalism will be grounds for continued denial of credit for training and result in a disapproval to take the certifying examination. Additional information can be obtained by contacting the ABP.

ABP Monitoring Plan Requirements (for period of observation for lapses in professionalism):

• If the learner is still in training, the remediation plan is at the discretion of the program director and does not require official review from the ABP.
• If the learner has been evaluated as unsatisfactory in professionalism, but has been determined to be otherwise clinically competent at the end of training , a remediation plan must be developed in conjunction with the ABP.  Development of such a plan must include four critical elements.  Initially, the plan must describe clearly the lapses which lead to the unsatisfactory performance in professionalism.  Secondly, the trainee must describe significantly how this behavior has affected others.  The third section should detail the monitoring plan and specifically how multi-source feedback will be used.  Lastly, any additional interventions that are required should be described.   Forms required can be referenced in the toolkit provided by the ABP. This toolkit will be sent when the program director documents an unsatisfactory professionalism performance and observation is recommended at the end of training. The ABP will approve the plan for observation.   
• Monitoring phase- A designated observer will be required to provide quarterly reports to the ABP for review by the ABP’s Credentials Committee.

Key Points

• It is challenging to identify and remediate lapses in professionalism but it is essential to the development of a learner and a key responsibility of a program director.  A program director needs to be familiar with strategies and tools that are available both internal and external to one’s department and institution.
• Programs should have a policy that addresses lapses in professionalism and the basics of remediation that may be applied to a learner.
• An organized approach to the creation of a remediation plan is recommended to aid in the achievement of successful correction of a professionalism deficiency.
• Knowledge of the ABP requirements and actions for unsatisfactory professionalism evaluations are important.

References

1. Buchanan AO, Stallworth J, Christy C, Garfunkel LC, Hanson JL. Professionalism in Practice:  Strategies for Assessment, Remediation, and Promotion.  Pediatrics. 2012 Mar;129(3):407-9
2. Hauer KE, Ciccone A, Henzel TR, Katsufrakis P, Miller SH, Norcross WA, Papadakis MA, Irby DM. Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice:  A Thematic Review of the Literature.  Acad Med. 2009 Dec;84(12):1822-32.
3. Byyny, Richard L., Maxine A. Papadakis, and Douglas S. Paauw. "Medical Professionalism Best Practices." 2015. MS. Menlo Park. Alpha Omega Alpha Honor Medical Society, 2015. Web. 11 Feb. 2016. http://www.alphaomegaalpha.org/medprof2015.html#Text. 
4. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring, and addressing  unprofessional behaviors. Acad Med 2007; 82: 1040–48.
5. Brigham and Women’s Hospital. Center for Professionalism and Peer Support. http://www.brighamandwomens.org/medical_professionals/career/cpps/. Accessed May 25, 2014.
6. Guerrasio J, Garrity MJ, Aagaard EM. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006–2012. Acad Med 2014; 89: 352–58.
7. Papadakis MA, Paauw DS, Hafferty FW, et al.  Perspective:  The education community must develop best practices informed by evidence-Based Research to Remediate Lapses of Professionalism. Acad Med 2012; 87: 1694-98.