Maxine A. Papadakis, M.D. Professor of Medicine UCSF 1/15/2019 Classifying lapses of professionalism around behaviors; an organizational tool to determine best practices for remediation Maxine A. Papadakis, M.D. Professor of Medicine UCSF S. Breanndan (Brendan) Moore death notice by his neighbors

It is a privilege and a joy to be involved in the education of medical students and residents

Behaviors are derived from the foundational system of professionalism Why focus on behaviors? Functional for teaching Standardized assessment Competencies and milestones Performance-based for educational advancement

Assessment of Professional Behavior Methods Used in U. S Assessment of Professional Behavior Methods Used in U.S. Medical Schools

What do we know about remediation? 1/15/2019 What do we know about remediation? National Board of Medical Examiners study “There is an urgent need for multi-institutional, outcomes based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.” K. Hauer et al Acad Med 2009 There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Behavioral Domains 1. Responsibility 2. Capacity for self-improvement   2. Capacity for self-improvement   3. Relationship with patients 4. Relationship with the health care environment Behavioral Domains

1. Responsibility Unreliable attendance at clinic 1/15/2019 1. Responsibility Unreliable attendance at clinic Problematic notification about missed activities Not following up on activities related to patient care Late or absent for assigned activities Unreliable   In Brandeis's view, a profession has three characteristics. First, it is an occupation for which the necessary training is intellectual, involving knowledge and learning as distinguished from skill. Second, it is an occupation pursued largely for others. Third, it is an occupation in which the amount of financial return is not the accepted measure of success. In my view, compliance satisfies all three per John Walsh

2. Diminished capacity for self improvement 1/15/2019 2. Diminished capacity for self improvement Failure to accept constructive criticism Brusque, hostile or argumentative Negative or poor attitude Arrogant Overconfident Overly sensitive In Brandeis's view, a profession has three characteristics. First, it is an occupation for which the necessary training is intellectual, involving knowledge and learning as distinguished from skill. Second, it is an occupation pursued largely for others. Third, it is an occupation in which the amount of financial return is not the accepted measure of success. In my view, compliance satisfies all three per John Walsh

3. Relationship with patients 1/15/2019 3. Relationship with patients Impaired relationships with patients Failure to establish rapport Insensitive to patient needs In Brandeis's view, a profession has three characteristics. First, it is an occupation for which the necessary training is intellectual, involving knowledge and learning as distinguished from skill. Second, it is an occupation pursued largely for others. Third, it is an occupation in which the amount of financial return is not the accepted measure of success. In my view, compliance satisfies all three per John Walsh

4. Relationship with the health care environment 1/15/2019 4. Relationship with the health care environment Not respectful to members of the health care team Creating a hostile educational environment Testing irregularities Falsification of patient data In Brandeis's view, a profession has three characteristics. First, it is an occupation for which the necessary training is intellectual, involving knowledge and learning as distinguished from skill. Second, it is an occupation pursued largely for others. Third, it is an occupation in which the amount of financial return is not the accepted measure of success. In my view, compliance satisfies all three per John Walsh

Patterns of behaviors Timing in training when behaviors are displayed Foundational sciences? Clinical interactions? Severity of lapses Repetition of behaviors and whether there is a trajectory for improvement How does faculty know when remediation has been achieved?

Vignettes

Late student Repeatedly shows up late for didactics, small group sessions, and start of call. Tardiness ranges from 10-30 minutes. Either does not acknowledge tardiness or has an imprecise excuse for being late. His peers are aware of the tardiness.

Demanding student Is insensitive and demanding to others. Often interrupts fellow students during their presentations. Nurses feel that student is self-centered, impatient, & arrogant. Staff notes that student complains about not getting the “perfect” clinic schedule & requests changes to assignments. Student rejects claims that evaluations are valid; believes faculty discriminates against her because of her disability

Medicine clerkship student Enthusiastic about science of diseases High MCATs (40) & high score on medicine shelf exam Disrespectful and arrogant towards staff but not to evaluators Defensive in accepting constructive criticism Criticizes the subjective nature of evaluations ; claims his intent is laudable