Unprofessional Behavior among Medical Students
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The real shocker in the report by Papadakis et al. (Dec. 22 issue)1 regarding disciplinary action by medical boards is the enormous prevalence of unprofessional behavior among medical students in the control group (nearly 20 percent). If unprofessional students become unprofessional doctors, then we face a real crisis, with huge numbers of unprofessional physicians currently in practice.
Medical students are reflective of society at large. Lack of professionalism among medical students is hardly surprising when high schools and colleges seem rife with unethical behavior that seems to be tolerated by society, including Internet plagiarism, résumé falsification, and computer-aided cheating. Even if "professionalism can and must be taught and modeled," as Papadakis et al. assert in their article, I am not optimistic that medical schools by themselves can inculcate ethical values if the previous 20-plus years of exposure to parents, clergymen, and numerous teachers were unsuccessful.
How can medical schools respond besides teaching professionalism? I suggest that schools closely examine whether their current educational formats include features that actually foster undesirable behavior. In addition, schools should increase their screening for mental illness among students with undesirable conduct; the types of unprofessional behavior listed in the article seem remarkably similar to classic symptoms of major depression.
Allan R. Glass, M.D.
4853 Cordell Ave.
Bethesda, MD 20814
References
Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005;353:2673-2682.
To the Editor: What is most interesting in the article by Papadakis et al. and the accompanying editorial by Kirk and Blank1 is not necessarily the finding that poor behavior in medical school predicts later unacceptable career actions but, rather, the question of why such behavior is even identifiable. To be sure, we know that bad behavior repeats itself throughout training (including during medical school, internship, and later), and it is generally obvious who the problem trainees are. Thus, given the ready identification of such trainees, why isn't this problem appropriately managed? Unfortunately, the answer is that the medical community does a poor job of self-regulation at many levels, including during training. Indeed, bad behavior is only the tip of the iceberg; for every ill-behaved physician, there are many others whose competence is borderline. Although training programs in the United States have developed many outstanding and wonderful physicians and numerous areas in medicine are flourishing, our profession can do better. We need improved methods for handling problem behavior and proficiency. More important, such procedures must be rigorously implemented.
Don C. Rockey, M.D.
University of Texas Southwestern Medical Center
Dallas, TX 75390
don.rockey@utsouthwestern.edu
References
Kirk LM, Blank LL. Professional behavior -- a learner's permit for licensure. N Engl J Med 2005;353:2709-2711.
To the Editor: Papadakis and colleagues note the close association between unprofessional behavior in medical school and subsequent disciplinary action by state medical boards. The use of drugs or alcohol, which accounts for nearly 15 percent of violations leading to disciplinary action, is the most common type of unprofessional behavior they report. Previous studies have revealed that binge drinking and drug use are just as common among medical students as they are among other young adults.1,2 It is reasonable to conclude that since the cause of unprofessional behavior may be underlying alcohol or drug abuse, detection and treatment of the problem before graduation may help prevent harm to patients and subsequent disciplinary action at the state board level.
Albert B. Lowenfels, M.D.
New York Medical College
Valhalla, NY 10595
lowenfel@nymc.edu
References
Mangus RS, Hawkins CE, Miller MJ. Tobacco and alcohol use among 1996 medical school graduates. JAMA 1998;280:1192-3, 1195.
Ghodse AH, Howse K. Substance use of medical students: a nationwide survey. Health Trends 1994;26:85-88.
To the Editor: Papadakis et al. state that their study of medical-student records and subsequent disciplinary action by medical boards was reviewed by the institutional review boards of the participating institutions. However, they do not make reference to the guiding authority on the privacy of student educational records in the United States, the Family Educational Rights and Privacy Act (FERPA). Although FERPA defines situations in which schools may disclose student records without consent, institutional review boards may not be the proper body to review the appropriateness of exemptions from the consent provisions. Information on the Web site of one of the schools that participated in the study (the University of Michigan) suggests that compliance with FERPA is the responsibility of the school's registrar. For studies that include the review of student records at U.S. schools, the Journal should consider requesting a statement about the review of FERPA compliance by the school's registrar or by the Family Policy Compliance Office of the Department of Education.
(The opinions expressed in this letter are those of the author and do not necessarily reflect those of Johnson & Johnson.)
Wayne R. Rackoff, M.D.
Johnson & Johnson
Raritan, NJ 08869
The authors reply: Dr. Glass points out the high prevalence of unprofessional behavior among the medical students in the control group. However, the severity of the unprofessional behavior among the controls was less than that among the physicians who received disciplinary action; severe irresponsibility was seen in 8.5 percent of the physicians who were disciplined by medical boards and in only 0.9 percent of the controls. We nonetheless agree that we should look to our programs to see where unprofessional behavior may be fostered. We also need to teach professionalism as a valuable component of our medical-school experience and to seek professionalism in our applicants. We also agree that students may not arrive in medical school with appropriate preparation for the demands of professionalism, and this lack may contribute to unprofessional behavior. However, we are encouraged that most students do acquire a professional attitude. The vast majority of practicing physicians take pride in their professionalism, and that is a virtue that we must celebrate.
We agree with Dr. Rockey that we need to do a better job of self-regulation. Our patients are entitled to nothing less, and our profession risks losing its ability to self-regulate unless we do so rigorously.1 We must also enhance methods to detect unprofessional behavior and borderline competency, develop remediation strategies, and study the outcomes of remediation.
Dr. Lowenfels appropriately raises the issue of underlying alcohol or drug abuse among medical students. We agree that this is an important issue, although we were not able to address it in our study.
Dr. Rackoff raises the issue of FERPA compliance for studies that involve records of medical students, beyond the approval of institutional review boards. Each of the three schools involved in our study was respectful of FERPA regulations, and appropriate procedures were used in the handling of confidential information to protect the identities of students. A legal opinion from the Office of the General Counsel at the University of California, San Francisco, was that our protocol complied with FERPA regulations for graduates of that institution. There was a discussion about the research project with the University of Michigan counsel, who rendered the opinion that the abstraction of data complied with FERPA regulations. We all worked, as well, to maintain the spirit of the law.
Maxine A. Papadakis, M.D.
University of California, San Francisco
San Francisco, CA 94143
papadakm@medsch.ucsf.edu
Susan L. Rattner, M.D.
Jefferson Medical College of Thomas Jefferson University
Philadelphia, PA 19107
David T. Stern, M.D., Ph.D.
University of Michigan Medical School
Ann Arbor, MI 48109
References
Stern DT, ed. Measuring medical professionalism. New York: Oxford University Press, 2006:v-viii.
Medical students are reflective of society at large. Lack of professionalism among medical students is hardly surprising when high schools and colleges seem rife with unethical behavior that seems to be tolerated by society, including Internet plagiarism, résumé falsification, and computer-aided cheating. Even if "professionalism can and must be taught and modeled," as Papadakis et al. assert in their article, I am not optimistic that medical schools by themselves can inculcate ethical values if the previous 20-plus years of exposure to parents, clergymen, and numerous teachers were unsuccessful.
How can medical schools respond besides teaching professionalism? I suggest that schools closely examine whether their current educational formats include features that actually foster undesirable behavior. In addition, schools should increase their screening for mental illness among students with undesirable conduct; the types of unprofessional behavior listed in the article seem remarkably similar to classic symptoms of major depression.
Allan R. Glass, M.D.
4853 Cordell Ave.
Bethesda, MD 20814
References
Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005;353:2673-2682.
To the Editor: What is most interesting in the article by Papadakis et al. and the accompanying editorial by Kirk and Blank1 is not necessarily the finding that poor behavior in medical school predicts later unacceptable career actions but, rather, the question of why such behavior is even identifiable. To be sure, we know that bad behavior repeats itself throughout training (including during medical school, internship, and later), and it is generally obvious who the problem trainees are. Thus, given the ready identification of such trainees, why isn't this problem appropriately managed? Unfortunately, the answer is that the medical community does a poor job of self-regulation at many levels, including during training. Indeed, bad behavior is only the tip of the iceberg; for every ill-behaved physician, there are many others whose competence is borderline. Although training programs in the United States have developed many outstanding and wonderful physicians and numerous areas in medicine are flourishing, our profession can do better. We need improved methods for handling problem behavior and proficiency. More important, such procedures must be rigorously implemented.
Don C. Rockey, M.D.
University of Texas Southwestern Medical Center
Dallas, TX 75390
don.rockey@utsouthwestern.edu
References
Kirk LM, Blank LL. Professional behavior -- a learner's permit for licensure. N Engl J Med 2005;353:2709-2711.
To the Editor: Papadakis and colleagues note the close association between unprofessional behavior in medical school and subsequent disciplinary action by state medical boards. The use of drugs or alcohol, which accounts for nearly 15 percent of violations leading to disciplinary action, is the most common type of unprofessional behavior they report. Previous studies have revealed that binge drinking and drug use are just as common among medical students as they are among other young adults.1,2 It is reasonable to conclude that since the cause of unprofessional behavior may be underlying alcohol or drug abuse, detection and treatment of the problem before graduation may help prevent harm to patients and subsequent disciplinary action at the state board level.
Albert B. Lowenfels, M.D.
New York Medical College
Valhalla, NY 10595
lowenfel@nymc.edu
References
Mangus RS, Hawkins CE, Miller MJ. Tobacco and alcohol use among 1996 medical school graduates. JAMA 1998;280:1192-3, 1195.
Ghodse AH, Howse K. Substance use of medical students: a nationwide survey. Health Trends 1994;26:85-88.
To the Editor: Papadakis et al. state that their study of medical-student records and subsequent disciplinary action by medical boards was reviewed by the institutional review boards of the participating institutions. However, they do not make reference to the guiding authority on the privacy of student educational records in the United States, the Family Educational Rights and Privacy Act (FERPA). Although FERPA defines situations in which schools may disclose student records without consent, institutional review boards may not be the proper body to review the appropriateness of exemptions from the consent provisions. Information on the Web site of one of the schools that participated in the study (the University of Michigan) suggests that compliance with FERPA is the responsibility of the school's registrar. For studies that include the review of student records at U.S. schools, the Journal should consider requesting a statement about the review of FERPA compliance by the school's registrar or by the Family Policy Compliance Office of the Department of Education.
(The opinions expressed in this letter are those of the author and do not necessarily reflect those of Johnson & Johnson.)
Wayne R. Rackoff, M.D.
Johnson & Johnson
Raritan, NJ 08869
The authors reply: Dr. Glass points out the high prevalence of unprofessional behavior among the medical students in the control group. However, the severity of the unprofessional behavior among the controls was less than that among the physicians who received disciplinary action; severe irresponsibility was seen in 8.5 percent of the physicians who were disciplined by medical boards and in only 0.9 percent of the controls. We nonetheless agree that we should look to our programs to see where unprofessional behavior may be fostered. We also need to teach professionalism as a valuable component of our medical-school experience and to seek professionalism in our applicants. We also agree that students may not arrive in medical school with appropriate preparation for the demands of professionalism, and this lack may contribute to unprofessional behavior. However, we are encouraged that most students do acquire a professional attitude. The vast majority of practicing physicians take pride in their professionalism, and that is a virtue that we must celebrate.
We agree with Dr. Rockey that we need to do a better job of self-regulation. Our patients are entitled to nothing less, and our profession risks losing its ability to self-regulate unless we do so rigorously.1 We must also enhance methods to detect unprofessional behavior and borderline competency, develop remediation strategies, and study the outcomes of remediation.
Dr. Lowenfels appropriately raises the issue of underlying alcohol or drug abuse among medical students. We agree that this is an important issue, although we were not able to address it in our study.
Dr. Rackoff raises the issue of FERPA compliance for studies that involve records of medical students, beyond the approval of institutional review boards. Each of the three schools involved in our study was respectful of FERPA regulations, and appropriate procedures were used in the handling of confidential information to protect the identities of students. A legal opinion from the Office of the General Counsel at the University of California, San Francisco, was that our protocol complied with FERPA regulations for graduates of that institution. There was a discussion about the research project with the University of Michigan counsel, who rendered the opinion that the abstraction of data complied with FERPA regulations. We all worked, as well, to maintain the spirit of the law.
Maxine A. Papadakis, M.D.
University of California, San Francisco
San Francisco, CA 94143
papadakm@medsch.ucsf.edu
Susan L. Rattner, M.D.
Jefferson Medical College of Thomas Jefferson University
Philadelphia, PA 19107
David T. Stern, M.D., Ph.D.
University of Michigan Medical School
Ann Arbor, MI 48109
References
Stern DT, ed. Measuring medical professionalism. New York: Oxford University Press, 2006:v-viii.