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  • Viewpoints

    A rude awakening

    From chronic absences to nasty emails, unprofessional behavior can derail even the most promising medical student’s career. The chair of one school’s conduct committee has a solution.


    Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

    I chair the Committee on Student Performance and Conduct at the Geisel School of Medicine at Dartmouth. Our students are extremely talented, highly sought-after individuals. Why, then, is my committee so busy?

    Occasionally, students face academic problems. The reasons are varied: Some may have failed an exam or two and need help honing their study skills. Others might be dealing with social or personal challenges that affect their ability to focus fully on their schoolwork.

    Unfortunately, it’s the cases of bad behavior that devour our time.

    Mind you, there aren’t many of them: Only about 1% of our 400 students exhibit poor professionalism. But our committee—which is remedial, not punitive—spends a great deal of effort managing that small group.

    “Only about 1% of our 400 students exhibit poor professionalism. But our committee . . . spends a great deal of effort managing that small group.”

    What's more, those students engage in the same kinds of bad behavior over and over. They are fine in front of patients but misbehave more on the edges of care. Among the failures, we see frequent late assignments, chronic unexcused absences, and highly unprofessional communications. One student who objected to certain assignments repeatedly, publicly, and disrespectfully railed against a faculty member. Another emailed a professor to say that his upcoming retirement would be an improvement for the institution.

    Given such behaviors at my school and others, it is essential for medical students to learn the fundamentals of professionalism, and for leaders in academic medicine to learn how best to model and teach them.

    So much rides on future physicians’ professionalism. Completing assignments on time reinforces skills for timely posting of patient notes. Attending required classes strengthens reliability. Responding promptly to emails teaches responsiveness to nurses, insurers, pharmacies, and others. And using an appropriate tone in difficult circumstances is at the core of team-based patient care.

    In order to prevent professionalism lapses, it helps to understand why they happen. Students who misbehave do seem to appreciate the need to provide quality care to patients. But they tend to balk at the tedious, behind-the-scenes tasks that support the larger institution. Raised with a focus on individualism, they sometimes have great difficulty setting it aside to perform those “menial” but essential tasks.

    “Medical students with professionalism issues are three times more likely to face disciplinary action later in their careers.”

    Some students mistakenly believe that the steep tuition they pay entitles them to a degree or to certain services from faculty or staff. But their tuition pays for the opportunity to learn technical skills and the behavioral contracts that allow the larger health care system to work smoothly. Unfortunately, I’ve found that many students with professionalism problems resist feedback and refuse to accept responsibility for their bad behavior. Indeed, medical students with professionalism issues are three times more likely to face disciplinary action later in their careers, according to a 2005 New England Journal of Medicine article.

    Why is it so tough to effectively teach professionalism? Medical schools nationwide grapple with this question. In 2017, Academic Medicine published a 168-page collection of articles by faculty from more than 15 institutions. Among the issues they addressed is the lack of a definition of professionalism that holds up across diverse situations, specialties, regions, and time frames. Like the Supreme Court justice who described obscenity, we tend to simply “know it when we see it.”

    Of course, we need to acknowledge that some instructors don’t know—or forget—what professionalism looks like. They may model bad behavior themselves, treating students or colleagues disrespectfully. Certainly, such cases need to be addressed swiftly if we hope to inspire and instill professionalism in the next generation.

    But based on my committee chair experience, I believe that a key aspect in our difficulty teaching professionalism lies in a disconnect between the world in which we trained and the one our students know.

    Students’ constant access to electronic textbooks and online resources may make them wonder why they need to come to class, for example. In addition, Facebook, Instagram, and other social platforms make it easier for them to broadcast flip or harsh comments without seeing the effect of their words on the person they’re writing about. Students also sometimes claim that faculty cannot fully understand the modern stresses they face.

    So, we need students to teach their peers about professionalism. My medical school is developing a longitudinal curriculum that uses peer coaches in small groups. With guidance from experienced faculty who will moderate discussions, students will offer real-world contexts as they identify the qualities and behaviors required for professionalism today. For example, they will outline how they shift from casual communications on social media to the more formal communications needed professionally. Students will advise and support each other from the start of their preclinical years and as they develop their clinical skills. We hope to launch the course in 2019.

    When students start teaching each other about professionalism, one of the key lessons I hope they convey is a unified mission dedicated to providing excellent care. For physicians and other providers, professionalism is about becoming a stitch in a fabric that is worn, faded, and thin in some places. We must work together to protect its entirety in order to provide the best possible care to our patients.