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.  

Adina Kalet, MD, MPH Honored with the 2023 NBME Hubbard Award

Adina Kalet, MD, MPH Honored with the 2023 NBME Hubbard Award

Dr. Kalet, Director of the Kern Institute, is receiving the Hubbard Award from the National Board of Medical Examiners (NBME) at their 2023 meeting. In lieu of an in-person acceptance speeech, she created this video that encapsulates the trajectory of her educational research, asking the critical question, "Is trust an educationally sensitigve patient outcome?"

We hope you find this remarkable talk enlightening. The link is below in the NBME's announcement. 

FROM THE NBME ANNOUNCEMENT: Established in 1983, the John P. Hubbard Award recognizes individuals for their outstanding contributions to the pursuit of excellence in assessment in medical education. During his time at NBME, Dr. Hubbard led NBME into a new era of evaluation that resulted in the adoption of objective testing methods. The Hubbard Award recognizes individuals who have made a significant and sustained contribution to the assessment of professional competency and educational program development at any level along the continuum of medical education and delivery of healthcare. We are thrilled to announce the recipient of the 2023 John P. Hubbard Award is Adina Luba Kalet, MD, MPH. Please find below a link to Dr. Kalet's pre-recorded scholarly presentation: Click here to watch the 17-minute video.

Building Professional Identity and Higher Purpose

From the March 17, 2023 issue of the Transformational Times

Invited essay

Building Professional Identity and Higher Purpose  

Tom Hurtado, EdD  

 

We should help students think about their mission in medicine -- what it means to them personally -- and form a community around them, coaching them to think about the higher purpose of medicine. In this essay, Dr. Hutardo describes the RealMD proram, which encourages Relationships, Excellence, Authenticity, and Leadership ...

 

I was a complete outsider when I began meeting with first-year students in my new role, leading the Student Affairs team at the Spencer Fox Eccles School of Medicine at the University of Utah. Within only a few weeks of starting medical school, students were telling me, "I don't feel like myself" and "I am unsure about who I am anymore." This was different from my work with undergraduates who were beginning to adjust to college life. It was a bit shocking, considering how far in their academic journey these first-year medical students already had traveled. Their experiences, and the support they needed, became the genesis for me -- a non-MD -- to co-create something called a RealMD program. 

 

My Non-Linear Path & Three Tendencies 

 

Not unlike a first-year medical student, I felt like a fish out of water -- and unsure of what I had to offer -- as I settled into my new role at the medical school. My arrival followed several twists and turns, including an undergraduate degree in humanities and a master's degree in education leadership and policy. 

 

I learned from my humanities training to think critically and ask deep questions about why things exist as they do. Studying higher education as a graduate student, and working with undergraduates in Student Involvement, helped me see the benefits of hands-on training and co-collaborating with students, staff, and faculty. That said, I found existing leadership theories insufficient for career and identity development, despite the insights and informative framework and skills they provided. I wanted something more fundamental, and a natural next step tied to my interest in graduate populations, to guide my own self-discovery process. 

 

This perspective followed me to the medical school, and helped inform my observations as I began to interact with students and take stock of the learning environment. What I observed were three disturbing tendencies that my doctoral work later confirmed: 

 

1. Students experience a loss of autonomy within a few short weeks of medical school. 

2. Students do not want to appear vulnerable in front of faculty and peers and are prone to be help-avoidant. 

3. And finally, negative role modeling by physicians occurs throughout the continuum.  

 

Leaning into my professional experience in student affairs and my experience and interest in Professional Identity Development (PIF), I began thinking about potential interventions that could counteract these discouraging, observed tendencies, and help the university better help students. 

 

Building a PIF Program 

 

I quickly met Tony Tsai, an MBA, who had spent several years in academic medicine at the University of Michigan working in career services and curricular reform. His role at the University of Utah in education strategy complemented my position in student affairs. He was the first person to envision a learning environment infused with meaning and purpose to address the negative tendencies of medical students.  

 

Additionally, we envisioned building a program that was based on Professional Identity Formation (PIF), using Kegan’s adult development and Baxter Magolda’s self-authorship theories.  

 

Together, we pitched a leadership elective, thinking we could start working with a small group of medical students and build momentum. Our proposal was swiftly rejected due to our lack of MD credentials. Rather than question the rationale of the rejection, we worked outside the curriculum. We created a co-curricular series of opt-in events sponsored by Student Affairs. And in 2017, the RealMD Program started. 

 

RealMD is an acronym for Relationships, Excellence, Authenticity, and Leadership. The opt-in program was co-produced with medical students, staff, and faculty. It incorporates lunch sessions with physicians who tell their career stories openly and honestly; faculty coaching sessions based on PIF frameworks, and a self-reflection workbook.  

 

These offerings foster meaning, community, and purpose in the learning environment. They encourage students to ask for help, maintain their autonomy, and engage with positive role models. At first, a few students began to attend regularly, and these founding members became RealMD student leaders. Lunch sessions quickly grew to over 100 students attending consistently. Now, over half the student body participates in various elements of the program. 

 

These sessions were transformative. Even during the pandemic, and the most time-crunched part of students' academic lives, they made time to attend RealMD because it was meaningful to them. And it helped them reconnect to who they are and why they originally chose the medical field. 

 

In a recent episode of the RealMD podcast, student leader Brandon Wilde, described the program this way:  

 

RealMD is a space for students to reconnect with their “why” in medicine, why they came here in the first place. I like the language of space because I really think that it's in this threshold between something very personal and self-reflective in medicine and the other side being so communal, like community contemplation about all of our reasons in medicine. I think that builds rapport.  

 

Real MD started small, and grew into a community of students, staff, and faculty who see the value in self-discovery and gatherings focused on Professional Identity Formation. We begin the first year of medical school by helping students think about their mission in medicine; what it means to them personally. Then we form a community around them and coach them to think about their higher purpose in medicine. Not only do we believe this leads to a better student experience and future career fulfillment, but surveys and academic research (both qualitative and quantitative) show a positive impact on students. RealMD now is embedded in our medical school -- coupling co-curricular elements with faculty, and Personal Identity Formation coaches assigned to every student. 

 

One of our faculty coaches said the following about their coaching experience:  

 

Being a coach, in general, did make me reflect a bit more on what I am doing, especially during times of burnout. I found it necessary to “practice what I preach” in terms of wellness and ensuring my job aligned with my values. 

 

Through the PIF coaching process, not only do students connect with their individual purpose, but faculty also reconnect with their values. It is exciting to see the benefits of the program reaching across the continuum.   

 

I find myself feeling extremely grateful for my non-linear path into academic medicine and the deep collaborations that have led to a Professional Identity Formation-based program that started organically and has now been adopted whole heartedly by my institution. Going forward, Professional Identity Formation (PIF) will now be at the center of our new MD curriculum and many of the interventions explored in RealMD will be used as a basis for a wider, more concerted effort to engage students in a self-discovery process supported by the medical school.  

 

Similar to my experience, many institutions want to start a PIF program, but lack buy-in, are unsure about content delivery, and struggle to know where to start. To those schools that see the need and don’t quite know where to start, or how to help their students, it is surprising what can happen when a few students, staff, and faculty begin to see the need and work together. Change can happen. 

 

“RealMD gave me hope that things will get better. [It] expanded my perceptions of what is possible in medicine in an inspiring way. Got me in tune with my inner voice when I thought I’d lost it.”

– First Year Medical Student, University of Utah 

 

 

Tom Hurtado, EdD, is Sr. Director of Student Affairs and Professional Identity Formation at the Spencer Fox Eccles School of Medicine at the University of Utah