Reality in Training for Professionalism

Purpose To identify the degree to which interns’ reported experiences with professional and unprofessional behavior converge and/or diverge with ideal professional behavior proposed by the physician community. Method Interns at Wayne State University’s residency programs in internal medicine, family medicine, and transitional medicine responded to essay questions about their experience with professional and unprofessional behavior as part of a curriculum on professionalism. Responses were coded for whether they reflected each of the principles and responsibilities outlined in a major publication on physician professionalism. Content analysis included the frequencies with which the interns’ essays reflected each principle or responsibility. Additionally, a thematic analysis revealed themes of professional behavior that emerged from the essays. Results Interns’ experiences with professional and unprofessional behavior most frequently converged with ideal behavior proposed by the physician community in categories involving interpersonal interactions with patients. Interns infrequently reported experiences involving behavior related to systems or sociopolitical issues. Conclusions Interns’ essays reflect their concern with interpersonal interactions with patients, but they are either less exposed to or less interested in describing behavior regarding systems or sociopolitical issues. This may be due to their stage of training or to the emphasis placed on interpersonal rather than systems or sociopolitical issues during training. The authors recommend future proposals of ideal professional behavior be revised periodically to reflect current experiences of practicing physicians, trainees, other health care providers and patients. Greater educational emphasis should be placed on the systems and sociopolitical environment in which trainees practice. Acad Med. 2005; 80:371–375. Unprofessional behavior by physicians has been widely publicized, from fictional portrayals of arrogant, demeaning physicians on popular television to reports of illegal and unethical behavior contributing to medical errors and skyrocketing health care costs. Unprofessional behavior may begin before or during medical training; a recent study linked problematic behavior in medical school to subsequent disciplinary actions by a state medical board. The physician community has taken steps to address the issue, setting standards and delivering innovative curricula to train future physicians. Three of these are significant to the purposes of this project. First, although many definitions have been proposed, the Medical Professionalism Project, a collaborative effort by the ABIM (American Board of Internal Medicine) Foundation, the ACP (American College of Physicians) Foundation, and the European Federation of Internal Medicine wrote a Physician Charter that has been widely adopted as the standard. Published in 2002 in both the Annals of Internal Medicine and the Lancet, the charter states: Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The Physician Charter then specifies three fundamental principles and ten professional responsibilities that form the contract with society (see List 1). A follow-up article published 15 months later reported that the publication had been endorsed and reproduced in several journals around the world, including the major journals for the fields of internal medicine, surgery, obstetrics– gynecology, and dentistry, and had been translated into several languages. In addition, the follow-up article reported that several hundred U.S. and international newspapers had cited the Physician Charter in related stories and 65,000 reprints had been requested from around the world. In a second major step toward addressing the issue of physicians’ professionalism, the Accreditation Council on Graduate Medical Education (ACGME) declared professionalism to be one of six general competencies all physicians should possess and in 2001 began requiring that all residency programs document the teaching and assessment of their residents’ professional behavior as part of the accreditation process. Third, the major journals of nearly every medical specialty society have published descriptions of a range of curricula that teach and assess medical trainees in the area of professionalism. Medical educators are acutely aware that their curricula for teaching all competencies are not delivered in a vacuum. The nature of medical training inherently exposes medical students and residents to a social, economic, and political context that may or may not reinforce the principles taught in the medical schools’ labs Dr. Eggly is assistant professor, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan. Ms. Brennan is research assistant, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan. Dr. Wiese-Rometsch is assistant professor, Department of Internal Medicine, Wayne State University, Detroit, Michigan. Correspondence should be addressed to Dr. Eggly, 5th Floor Hudson-Webber, Karmanos Cancer Institute, Wayne State University, 4100 John R., Detroit, MI 48201; e-mail: [email protected] . Academic Medicine, Vol. 80, No. 4 / April 2005 371 and classrooms. Outside of the classroom, trainees face the vagaries and complexities of patient care and interactions with colleagues, faculty, and myriad other health care professionals. Therefore, the challenge to physicians and medical educators is to set standards, teach, and assess professional behavior in a way that converges with and builds upon trainees’ daily experiences rather than contradicts them. Although many publications have set standards and described strategies for teaching and assessing professional behavior, few have reported the daily experience of trainees. Surveys of medical students and residents reveal they frequently encounter challenges to professional behavior in the hospital setting. Baldwin et al., reporting the results of a survey of 571 second-year residents describing their observations of unethical and unprofessional behavior during their first postgraduate year, found that nearly half reported personally observing falsification of patients’ records by others and others taking credit for their work. Nearly two-thirds witnessed mistreatment of patients and colleagues working while impaired. Over a fourth of the residents reported being required to do something that was immoral, unethical, or personally unacceptable. Kasman et al. described emotions triggered by experiences during medical training in hospital settings, arguing that these responses affect professional behavior. Rosenbaum et al. interviewed internal medicine residents about their experiences with ethical and professional behavior and classified the responses into five broad categories: concern over telling the truth, respecting patients’ wishes, preventing harm, managing the limits of one’s competence, and addressing performance by others that is perceived to be inappropriate. In focus groups with medical students, Ginsburg et al. noted the gap between articulated principles of professionalism and students’ observations of lapses in professional behavior. As these reports demonstrate, a significant gap exists between the ideal standards set forth by the physician community and the daily practices observed and experienced by physicians-in-training. To teach and assess professional behavior, some residency program directors at Wayne State University require first-year residents (interns) to read a variety of published definitions of ideal professional behavior and respond in writing to three essay questions regarding their experience with professional and unprofessional behavior. In reading the essay responses, we were struck by the discrepancy between the definitions the interns were required to read and the experiences they described in their essays. This inconsistency motivated us to conduct a systematic exploration of the gap between the ideal and the real with regard to physicians’ professional behavior. In this report, we answer two research questions: Research Question 1: To what extent do the interns’ reported experiences with professional and unprofessional behavior converge and/or diverge with the categories of professional behavior considered by the physician community to be ideal? Research Question 2: How do the interns’ reported experiences extend these categories of professional behavior?