Chapter Authors: Debra Boyer, MD, and 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 learner's 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 or 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 learners to their baseline of professional behavior. Guidance should be offered by the program director, but counseling should be left to a qualified external professional.
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 toward 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 following3:
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 trainees seeks the kind of help that they needs in order to return safely to work.
What Constitutes Egregious Action
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