Research Finds Poor Physician Habits Begin Early

By Suria Santana

Maxine Papadakis, M.D., associate dean of student affairs, UCSF School of Medicine

A new study has confirmed the fears of many medical educators: a student's unprofessional behavior in medical school is highly likely to be replicated later in his or her career.

In a recent Journal of Academic Medicine article, Maxine Papadakis, M.D., professor of clinical medicine and associate dean of student affairs at the University of California, San Francisco (UCSF) School of Medicine, released the results of a study linking unprofessional behavior in medical school with subsequent disciplinary action by a state medical board.

Dr. Papadakis reviewed the records of former UCSF medical students who had faced disciplinary action by the Medical Board of California between 1990 and 2000 and found that 95 percent of their cases involved deficiencies in professionalism. After looking at the physicians' academic files, she discovered that many of them had received comments about unprofessional behavior in medical school. She also found that the students who received such comments were more than twice as likely to be disciplined by the medical board.

"This study provides evidence-based data that the assessment of professionalism is an important competency," said Dr. Papadakis. "This means that students should be able to demonstrate professionalism in order to graduate from medical school." Students who are proficient in the traditional competencies of scientific knowledge and clinical skills but who display unprofessional behavior while in school should not be allowed to graduate, she added.

Dr. Papadakis and the other researchers involved in the study are now working with the Federation of State Medical Boards (FSMB), the University of Michigan and Jefferson Medical College to test the applicability of the study in other states.

David Stern, M.D., Ph.D., associate professor of internal medicine and medical education at the University of Michigan, is one of the co-investigators in the follow-up study. He said that the results of Dr. Papadakis' research did not come as a surprise to most medical educators.

"The study does send out a warning to deans, clerkship directors and other educators that we need to continue to improve our ability to document unprofessional behavior on the part of medical students and gain confidence in the implications of such events," he said.

Dale Austin, chief operating officer of the FSMB, believes that the study's findings are likely to be echoed in other states. "Given what I've read, I don't have any reason to believe that the results would be different elsewhere," he said.

Dr. Papadakis' conclusions resonated with observations made by his organization's members.

"Time and time again, board members have told me that the individuals that they take action against in their state can have their problematic behavior traced back to postgraduate training years, even into medical school," Austin said.

Schools' efforts

Medical schools are already involved in efforts to assess and record their students' professional behavior. One system currently used by many institutions has been dubbed the "critical instances reports." If the dean gets two or three reports on a single student, he starts tracking his or her behavior and could eventually take disciplinary action against the student.

"These reports lower the radar screen for unprofessional behavior, and allow faculty to identify single instances of unprofessional behavior and report them to a dean," Dr. Stern explained.

Examples of other professionalism related efforts include lectures on ethics, small group work on professionalism topics, standardized patient exercises that include ethical and professionalism elements and literature and medicine lessons that promote reflections on professional behavior.

Dr. Stern is working on a book, scheduled for publication next year, that addresses the measurement of medical students' professional behavior. The book will contain practical information, including the different professionalism evaluation tools being used or developed by educators around the country.

"Each chapter will be written by an expert in the field who is working to develop a particular method," he said.

Besides developing effective techniques to measure professionalism in students, it is important to teach professionalism and find ways to appropriately handle the cases in which students are found to be lacking in that arena, according to Dr. Papadakis.

"We really need to work on remediation strategies, and we need to have outcome data on the successful remediation approaches," she said.

Educators need to continue to articulate that professionalism is a skill that deserves as much weight as the other academic competencies, Dr. Papadakis stressed. "If we believe that, then all the related administrative and academic consequences will just fall into place."

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