Professionalism Lapses in GME: Oops, Can’t, and Won’t

From the August 4, 2023 issue of the Transformational Times

Professionalism Lapses in Graduate Medical Education: Oops, Can’t, and Won’t 

Chad Carlson, MD, FAAN 

Program Director Carlson shares takeaways about remediation in residency training: Intent is important. In broad terms, the categories of “oops,” “can’t,” and “won’t,” divide learners into those who have a lapse in behavior they know and understand, those who currently lack or cannot access a set of skills or tools, and those who choose not to do something, despite having access to and knowledge of the appropriate path forward... 

Anyone involved in medical education, regardless of the level of learners, can relate to issues of professionalism in situations needing to be addressed.  If you are like me, this is followed by a pit in the stomach and concerns about the best next steps: Can I fix this? How do I help? Is this even a “fixable” problem?

These thoughts are often compounded by a feeling of relative isolation; while we all help learners address these issues, we often feel like we are doing so in a relative vacuum. Often, our own experiences and feelings complicate remediation and lead to the belief that these sorts of problems cannot be fixed.  

The concerns and limitations program directors face in addressing issues of professionalism prompted us to focus on this topic at the Medical College of Wisconsin Affiliated Hospitals (MCWAH) Program Directors retreat. A presentation and discussion session led by invited speakers Betsy Williams, PhD, MPH, FSACME (Clinical Director of the Professional Renewal Center) and Karen Warburton, MD, FASN, FACP (Associate Professor of Medicine and Director of GME Advancement and Clinician Wellness Program at the University of Virginia Health System) outlined several key features and highlighted some common themes. The retreat also focused on the potentially daunting topic of remediation of professionalism issues in graduate medical education through interactive and case-based talks. 

Key takeaway: Professionalism issues are not inherently irremediable.

The process of remediation itself can be broken down into: Identification, Assessment, Active Coaching, and Ongoing Evaluation

Identification has already occurred if you have a pit in your stomach about what comes next with a resident. But most medical educators can recall situations where, if they had better documentation or more feedback or input, they would have better understood both the scope and nature of issues with a learner. The earlier that identification occurs, the less likely it will negatively impact the timing of training for a learner. Dr. Williams lamented the frequent occurrence of hearing about a struggling learner in April or May of their final year of training when there is little time to implement an effective coaching plan.  

Within the realm of assessment, intent is important. The difference between an “oops,” “can’t,” and “won’t,” is an important distinction.  

In broad terms, these categories divide learners into those who have a lapse in behavior they know and understand, those who currently lack or cannot access a set of skills or tools, and those who choose not to do something, despite having access to and knowledge of the appropriate path forward. 

A comprehensive assessment also includes looking for potential mental health contributors. Evidence supports that about a third of struggling learners have an underlying mental health concern such as anxiety, depression, and cognitive or learning disorders. It is no surprise these underlying conditions often contribute to a “can’t.” 

The results of the assessment should drive the approach to coaching (or discipline). 

While a program or course director’s approach is often to take the lead on remediation or other issues to spare busy faculty colleagues and team members, in these settings, the program director may not be the best person to do the coaching. 

Involve someone not part of the Clinical Competency Committee (or recuse that person from discussions in the Clinical Competency Committee if this is unavoidable).  

Planning the intervention

In planning the type of intervention, the concept of intent is important. 

• Support with little formal coaching is likely adequate for an “oops." 
• Formal coaching is typically necessary for a “can’t.” 
• In the case of a “won’t,” rapid escalation beyond coaching to formal disciplinary measures may be necessary. 

In thinking about a “can’t,” we need to consider both the realm of teaching about professional norms and recognize when there are barriers (personal or systemic) to following them. 

As educational leaders, we need to look at individual professionalism violations and consider whether the issues represent a broader systemic issue or are related to individual factors alone. 

Ongoing systemic monitoring and intervention is critical 

Importantly, whatever the remediation methods, one cannot think of this as a single episode or course of treatment; a systemic approach for regular monitoring and evaluation must be in place to identify potential lapses in professionalism, prior to them rising to the level of a problem.   

The systematic approach to thinking about issues of professionalism was a welcome discussion during the retreat. But perhaps more important was the recognition that these are challenging, but not insurmountable problems with which we, as educators, all struggle. 

The desire to help our students, residents, and fellows succeed is--and should be--strong. But the frustration and disappointment when those expectations are not met is very real for all involved. This can be particularly true in graduate medical education, where we work closely with small classes of trainees, typically for multiple years. These personal bonds can be both a strength and a liability when professionalism is challenged.   

Our community of educators is our greatest resource

Our community of educators committed to improving learner well-being is, undoubtedly, our greatest resource; learners struggling with professionalism issues are not unique to any one campus, course, or program. We can, and should, make use of the depth of expertise across the institution instead of staying in silos in our individual departments and programs.   

Drs. Warburton and Williams made it clear through their experience and work on this topic that learners who encounter these issues can, in most cases, be helped and put back on a path to success. 

Proper diagnosis and management, just like in patient care, is the key to success. 

Chad Carlson, MD, FAAN, is a Professor in the Department of Neurology at Medical College of Wisconsin and serves as the Program Director for the Adult Neurology Residency, Associate Program Director for the Clinical Neurophysiology and Epilepsy Fellowships, and Vice Chair of Education.