Promoting Professionalism in Medical Education: A Toolbox for Effective Feedback and Remediation

Professionalism in medicine reflects our ethos and commitment to the field. The American Board of Medicine defines professionalism in medicine as: ‘a normative belief system about how best to organize and deliver health care, which calls on group members to jointly declare (‘profess’) what the public and individual patients can expect regarding shared competency standards and ethical values and to implement trustworthy means to ensure that all medical professionals live up to these promises’ [1]. Professionalism is critical to the practice of medicine. Lapses in professionalism undermine physician-patient relationships, deteriorate team morale and hinder the efficiency of clinical care. A study of University of California San Francisco graduates who faced the California Medical Board over a 10-year period, 95% of disciplinary actions were due to deficiencies in professionalism, and obstetrician-gynaecologists were overly represented in those (14% of all those who faced disciplinary action but only 4% of grads) [2]. These behaviours did not simply emerge during practice; the physicians who were disciplined by the Board for unprofessional behaviour were twice as likely as graduates in the control group to have received negative comments regarding professionalism during medical school. This association between early challenges with professionalism and subsequent state medical board disciplinary actions suggests that medical educators may be unable to effectively remediate professionalism concerns in a way that alters subsequent behaviour as clinical faculty. In the clinical learning environment, providing constructive feedback and correction to learners, primarily residents and medical students, is crucial to their development and success as physicians. Medical educators have consistently identified unprofessional behaviour as a common reason for learner remediation [3], yet providing feedback on professionalism remains a significant challenge. Barriers to providing constructive feedback in an objective and timely manner include lack of time, fear of learners' responses and lack of clear goals and objectives in training programs [4]. In addition, learners may perceive feedback on professionalism as subjective and may feel targeted by the feedback; it may be perceived as criticism of character or personality traits [5]. Due to the uncomfortable nature of this type of feedback, many clinical faculty opt to note these concerns only on summative written evaluations rather than addressing them in real time. Thus, program directors and clerkship directors often find themselves providing feedback to learners on behaviours that they did not directly observe and that may have happened several weeks prior. Using our varied experiences as teaching faculty, clerkship leadership and residency program leaders and the best available data we designed a novel framework for approaching lapses in professionalism centred around Professional behaviour, Action, Communication and Timeline (PACT). We present a toolbox to inform and facilitate the implementation of the PACT framework to improve educational leaders' delivery of formal feedback on unprofessionalism, drawing upon our personal experiences with different groups of learners to help others consider how to best promote professionalism in the modern medical era. Through early recognition and intervention via a uniform approach to professionalism lapses, we aspire to reduce future recurrence for learners in the health professions. We designed a novel framework for approaching lapses in professionalism centred around Professional behaviour, Action, Communication and Timeline. Trainees learn about professionalism from peers, faculty and other role models and breaches in professionalism by faculty and role models can imply acceptance of unprofessional behaviour. One study illustrated that all learners had observed unprofessional behaviour by faculty, ranging from harsh remarks to unwanted advances [6]. This negative role-modelling inherently contributes to learners' fundamental understanding of professionalism. Institutions all have professionalism standards, but it is variable to what extent these are communicated to learners of various levels. Sharing these expectations is of paramount importance, given the prevalence of professionalism concerns that can arise during training. When reviewing remediation nationally in obstetrics and gynaecology residency programs, 85% of programs had placed a resident on a remediation program, and the most common reason for remediation was due to breaches in professionalism [7]. Sullivan et al. identified unprofessional behaviours including absenteeism, tardiness, disrespectful language, lack of accountability and professional misconduct. These behaviours exist along a continuum (Box 1), and the authors graded these behaviours on levels of severity and urgency of need for remediation [8]. The first aspect of our framework focuses on making sure the learner is approached with objective and discrete observations on behaviour as nonspecific and subjective feedback does not provide a clear path for improvement. Institutions all have professionalism standards, but it is variable to what extent these are communicated to learners. Additionally, standardizing the approach to professionalism mitigates implicit bias and allows medical educators to approach remediation fairly and objectively. Multiple studies have demonstrated possibilities of gender bias in evaluations of residents, particularly surgical residents, and we believe a uniform approach focused on objective data may help mitigate this [9, 10]. Leaders should be familiar with resources on recognizing and mitigating bias that are available from the Accreditation Council for Graduate Medical Education (ACGME), American College of Obstetricians and Gynecologists (ACOG) and other professional organizations [11]. Recognizing similarities between professional development and healthcare system quality improvement (QI) efforts we start our framework with an assumption that all learners and staff in the clinical learning environment had the best intentions and we also note that hospitals are intensely stressful areas and are cognitively demanding for all participants [12]. In our experience, the use of this technique helps mitigate the feeling of persecution that learners often feel when approached about feedback around professionalism. Acknowledgement and recognition of the factors that contribute to unprofessional behaviour are also crucial in investigating professionalism concerns, as they inform opportunities for coaching and targeted interventions (Box 2) [13]. For example, a resident who behaved in an unprofessional manner may be responding to a negative workplace culture or what was implied to be an acceptable behaviour [6]; eventually both issues would need to be addressed to adequately manage the reports of unprofessionalism. Ultimately when considering the promotion of professionalism to be akin to a QI endeavour, the goal is to seek ways for improvement rather than to place blame while acknowledging individual responsibility and systemic challenges. In QI, the process of case review and data analysis leads to the implementation of sequential changes through Plan, Do, Study, Act (PDSA) cycles and creates a system that supports evidence-based decisions. For learner development and remediation, individual support and feedback for growth should be paired with cultural change that promotes professional behaviour. When a leader approaches the investigation step, they can identify various pressures that led to this behaviour and ways to address them as well as a sequential, iterative process to improve ‘outcomes’ for the learner. Local programs such as the midterm feedback for medical students and the clinical competency committee (CCC) and semi-annual review for residents provide opportunities for leaders to understand their clinical learning environment outside of the acute problems presented. Constructive feedback, while crucial to learning and growth, is often hindered by time constraints, fear of retaliation, remediation concerns and fear of psychologically harming learners [14]. Critical feedback on professionalism in particular can often challenge one's view of self, due to its close link to learners' identity. While professionalism is a core competency in medical education at the undergraduate and graduate levels, professionalism can be challenging to objectively assess, as even existing scales tend to address only a single facet of professionalism [15]. Existing methods are inadequate to identify professionalism issues, and there is significant variability in how lapses are recognized and reported. Educators may receive feedback from various sources, including patients, nurses or faculty not directly engaged in teaching, or may receive feedback anonymously through professionalism reporting lines, which are commonly used in academic medical centres to meet regulation guidelines. It then falls to educational leaders to provide formative feedback on unprofessionalism to the learner, which is exacerbated further as the behaviour reported was not observed by the leader themselves. Best practices exist to provide feedback in the clinical environment; these core principles can be translated to professionalism feedback whether it is in a clinical environment or an administrative environment [14]. An objective, performance-based description of the behaviour, and an explicit explanation of how it deviates from existing professionalism guidelines or expectations, is an important starting point for any feedback session on unprofessionalism. Educators should ensure that learners can share their perspective and reflect on factors that impacted their behaviour. This step not only elicits another viewpoint surrounding the events (which you did not witness yourself) but serves as a safeguard for professionalism reports that may include bias. Educators should ensure the learner understands and accepts the feedback by developing an agreed-upon action plan to which the learner commits. Using these core principles as well as best practices for professionalism related and drawing from our own experiences, we created a sample script for educational leaders to utilize (Box 3) [16]. When communicating with the learner, educators can use scripting to help maintain focus on objective behaviours and drive the conversation, which is particularly important as emotionally charged feedback can be stressful not only to receive but also to give. Another common barrier to addressing professionalism is the lack of a uniform approach to remediation. Whereas remediation of medical knowledge and procedural skills is typically addressed by schedule modifications that target the area of deficit, deficits in professionalism tend to be broader and need nuanced interventions. In fact, 80% of emergency medicine program directors felt that professionalism was more challenging to remediate than any other problem, due to two major concerns: (1) lack of a uniform approach to remediation and (2) learners' accountability [8]. While the general idea of remediation should be the same, with sequential targeted interventions and improvements (just like in a QI PDSA cycle), remediation of professionalism deficits is difficult to standardize as the problems are more likely to be individual. Breaches in professionalism may be signs of mental health issues or challenging life events, especially concomitant burnout [17]. In order to best understand how to ensure successful remediation, having a thorough understanding of any additional factors that could impact the individual learner will allow for implementation of an appropriate plan. Not only must the individual learner have some accountability or ownership of their lapses and be self-reflective about continuous improvement, but educators must promote a positive learning environment in the training program [18, 19]. Ultimately, the framework concludes with a timeline for remediation and subsequent check-ins to reinforce the importance of shared accountability between the educator and trainee to help ensure competency in the professionalism domain as a crucial component of training. Through our own experiences with the PACT framework for addressing professionalism lapses, we have offered examples of remediation plans and timelines (Box 4). The PACT framework (Box 5), was developed in response to a need felt by the authors in their various academic roles (residency program leadership, residency rotation director, clerkship leadership). Ultimately, we designed this framework to help educators create an easy-to-use standardized approach to improving professional behaviour in medical training and have outlined the rationale for each element of the framework above. In each of our roles, we have personally utilized the framework and found that it decreased our own anxiety surrounding professionalism feedback/remediation and improved learner receptiveness to feedback. This framework was designed with two main goals: easily adaptable to clinical and administrative environments at any institution and to overcome the common ‘pain points’ educational leadership feels when addressing undesirable behaviours. To make it easy to use, educators can utilize existing policies, such as an existing ‘code of conduct’ from their college or school of medicine, to help frame the validity and severity of the lapse in the context of institutional policies. The framework empowers educators to address and prevent further lapses by recognizing how intrinsic and extrinsic pressure can predispose learners to lapses in professionalism and by following a predetermined remediation policy. In our experience, scripting ensures that when learners are informed of the lapse, they have an opportunity to share their perception of events; a shared understanding and commitment for change must be made for remediation attempts to be successful. The authors have personally utilized this framework across our own separate institutions, fields, and learner groups and found it to be applicable and adaptable. Future work would involve disseminating this framework more widely and following up with individuals who have used it to explore what iterative changes are beneficial across a wider range of institutions and programs. Exploring learner perceptions of professionalism feedback and remediation with such a framework would further support its effectiveness. Finally, a longitudinal study could explore how these strategies influence long-term professional behaviour in medicine. The modern clinical learning environment brings together a great diversity of accepted normative behaviour that collides with the inevitable stress of working in heterogeneous teams taking care of increasingly complex patients while trying to train providers and staff simultaneously. Conflict will arise and frequently encourages unwanted behaviour. Faculty must be committed to supporting their learners' professional development, which means correcting unprofessional behaviour and supporting growth and development. Our hope is to utilize a standard approach to setting expectations for all learners, with standard practices to address when behaviour falls out of the bounds of expectations to mitigate the challenges associated with remediation of professionalism. This was done outside of an experimental model and in the future, we plan to study if this framework is truly producing the results we have found when adapted by other users. Future dissemination of the PACT framework could be incorporated into faculty development workshops throughout the health professions to both reinforce professionalism best practices and optimize feedback delivery from faculty in the teaching environment. The PACT framework allows for feedback that is objective, focused on behaviours rather than personality traits and flexible enough to be used regardless of the severity of the professionalism lapse or the environment. It is built on a foundation of best practices from a variety of arenas that should be familiar to faculty and learners alike, including quality improvement, simulation and existing medical education canon. Faculty must be committed to supporting their learners' professional development, which means correcting unprofessional behaviour and supporting growth. Matthew R. Carroll: conceptualization, investigation, methodology, writing – original draft. Gal Barak: conceptualization, investigation, methodology, visualization, writing – review and editing. Tracy Byrne: conceptualization, investigation, methodology, visualization. Huma Farid: conceptualization, investigation, methodology, supervision, writing – review and editing. The authors have nothing to report. We did not utilize material from other sources; all figures were created by the authors and represent our own work. All references have been appropriately cited. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Scenario: Dr. Jones is a residency program director. A medical student reported that a resident Dr. Smith ‘was rude to a patient’. Dr. Jones would like to practice using the PACT framework to investigate, communicate and remediate this potential professionalism lapse. P: Upon receiving this report, Dr. Jones contacts the medical student leaders to elicit additional details about the report if available. Dr. Jones confirms no separate reports were submitted from nursing or patient experience and reflects on the risk of bias in the report (e.g., considering if a negative evaluation from the resident may have preceded the report). Dr. Jones deems the severity of the lapse as ‘serious’ (Box 1). A: Dr. Jones recognizes that the resident is on nights, and the reported behaviour occurred when covering an extra shift for another resident; Dr. Jones plans to explore contributing factors with Dr. Smith (Box 2). Finally, Dr. Jones reviews the resident handbook to reinforce existing policies and expectations in the discussion with Dr. Smith. C: In the meeting with Dr. Smith, Dr. Jones utilizes the sample script (Box 3). The authors have nothing to report.