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Professional Behavior — A Learner's Permit for Licensure
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     At probably no point in the history of modern medicine have physicians and medical educators been pulled by so many demands of accountability from such diverse constituencies. Although these demands are varied and sometimes even contradictory, all the constituencies concur that physicians must demonstrate professional behavior. In this issue of the Journal, Papadakis and colleagues1 provide evidence from three medical schools of the association between disciplinary action by state medical boards against practicing physicians and a documented lack of professional behavior (particularly, irresponsibility, diminished capacity for self-improvement, and poor initiative) when those physicians were medical students.

    William Sullivan of the Carnegie Foundation for the Advancement of Teaching recently pointed out that the call for renewed accountability to patients and the general public brings with it the collective empowerment of physicians. Professionalism flourishes only if the profession takes a leadership role in enforcing high standards of practice while inviting public response and involvement in the effort to clarify its mission and responsibility.2 And what is professionalism? A recently published, assessment-focused definition suggests that "professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical and legal understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability and altruism."3 Thus, "professionalism" denotes the standard of behavior that individual physicians are expected to meet as they provide their specific knowledge and skills to those who seek their counsel, and it is the basis of medicine's contract with society.4

    In historical terms, the seminal 1910 Flexner Report helped to define standards and structures for medical education. This definition resulted in a process-based continuum of medical education that was predicated on a system in which students would spend a defined amount of time in medical school and residency training, with exposure to a standard yet evolving curriculum. Competence was most reliably determined by measures of cognitive knowledge. Students and residents were promoted to the next level of education after demonstrating a mastery of that knowledge, until they were ultimately deemed competent to practice medicine independently.

    Those standards have served to create multiple generations of physicians responsible for addressing the health care needs of their patients. However, both individual and systems-based gaps in the provision of that care have been identified. Patients and the medical profession itself are demanding that students, residents, and practicing physicians demonstrate a defined set of "competencies" in addition to a mastery of appropriate medical knowledge. As a result, the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties — the standard-setting organizations involved in the continuum of medical education — have defined the domains of behavior that are essential for physicians to meet these competencies. Central to building the trust of patients is professionalism, the domain of competence most difficult to measure.5 Assessment of this competency is a complex, multistage task that involves observation, description, and the determination of values.3 Equally important is the teaching of professionalism in the service of healing, which has garnered significant focus and formal activity among medical educators over the past decade.6

    When the earlier work of Papadakis et al., which served as a pilot for this study, was published, many in medical education perceived it to be on target in identifying and classifying a spectrum of problematic behavior in students.7 This follow-up work identifies the presence of "irresponsibility" and "resistance to improvement" as the most significant predictors of unprofessional behavior, as defined by sanctions from licensing boards. Such sanctions are relatively rare and an extreme culmination of the recognition of unprofessional behavior. However, the public clearly expects the profession to aim for the highest standards. Also, it is likely that without intervention and remediation, these types of behavior during medical school can evolve to predict a spectrum of unprofessional behavior during graduate medical education and in clinical practice that constitute disruptive physicians and problem professionals. Data reveal that 3 to 10 percent of such physicians have increased rates of medical errors and malpractice suits; however, for a proportion of physicians, such unprofessional behavior can be remediated through structured educational programs that incorporate professional intervention, monitoring, and follow-up.8

    What are the implications for medical education of Papadakis and colleagues' findings?

    First, the evidence is in, and the link between unprofessional behavior among medical students and their subsequent unprofessional behavior as physicians is undeniable. Second, as the authors discuss, awareness and accountability are essential for all medical schools in order to affirm explicit expectations with regard to professional behavior on the part of medical students and residents and related standards of performance and feedback. These expectations may offer needed insight with which to inform and change policies involving admissions and promotion. The same need for transparency holds true for faculty and practicing physicians. Taking such actions as part of physician self-regulation works to uphold the regulatory contract between the public and the medical profession.9 Third, measuring professional behavior and other aspects of professionalism remains challenging but holds promise and can be achieved through multiple observations by many evaluators and through continuing faculty development. As the mandate advances for improvements in teaching, evaluation, monitoring, documentation, and feedback with regard to professional behavior, exploring the association of unprofessional behavior in residency training with subsequent disciplinary action against practicing physicians may shed further light on effective strategies of remediation. Data and experience showing the ways in which medical education can influence the professional behavior of physicians are likely to be applicable and to inform the education of other health professionals and other professions in general.

    In summary, the medical profession, especially medical educators, cannot wait until the optimal data and resources are available to teach and assess professionalism. We must take the information we have and act. Papadakis and colleagues have documented types of behavior that may serve as metrics for identifying students and physicians at greatest risk for unprofessional behavior and in need of remediation. These metrics can also serve to test the effectiveness of current and potential methods of teaching and assessment. The profession is expected to participate in the process of self-regulation, which includes the remediation and discipline of members who fail to meet professional standards.4 In today's climate, it is clear that if the profession is not accountable and cannot police itself, outside regulators will. Papadakis et al. make the case that the unprofessional behavior of students can lead to their unprofessional behavior as practicing physicians and that it provides a powerful link to adverse actions in licensure. This revelation also serves as a stimulus to look hard at what Jordan Cohen of the Association of American Medical Colleges calls "the learning environment, at the hidden curriculum — namely, at the cultural norms at work to inform the changes necessary to transform whatever crucibles of cynicism are found into cradles of professionalism. Indeed, the most important task facing medical educators today is having our students consistently demonstrate the attributes of medical professionalism."10 Patients, society, and the profession deserve nothing less.

    No potential conflict of interest relevant to this article was reported.

    Source Information

    From the University of Texas Southwestern Medical Center at Dallas, Dallas (L.M.K.), and the Association of American Medical Colleges, Washington, D.C. (L.L.B.).

    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.

    Sullivan WM. Work and integrity: the crisis and promise of professionalism in America. 2nd ed. San Francisco: Jossey-Bass, 2005.

    Arnold L, Stern DT. What is medical professionalism? In: Stern DT, ed. Measuring medical professionalism. New York: Oxford University Press, 2006.

    ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-246.

    Veloski JJ, Fields SK, Boex JR, Blank LL. Measuring professionalism: a review of studies with instruments reported in the literature between 1982-2002. Acad Med 2005;80:366-370.

    Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med 1997;72:941-952.

    Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79:244-249.

    Coombs JB, Brown M, Friedlander RB, Fabri PJ. The disruptive physician. Group on Resident Affairs Plenary Session II. Presented at the Association of American Medical Colleges Beyond Boundaries 2005 Annual Meeting, Washington, D.C., November 8, 2005.

    Irvine DH. A short history of the General Medical Council. Med Educ (in press).

    Cohen JJ. "The Work Ahead": AAMC president's address 2005. Washington, D.C.: Association of American Medical Colleges, November 6, 2005. (Accessed November 15, 2005, at http://www.aamc.org/newsroom/pressrel/2005/051106.htm.)(Lynne M. Kirk, M.D., and )