Maxine A. Papadakis, M.D. Professor of Medicine UCSF

1. Classifying lapses of professionalism around behaviors; an organizational tool to determine best practices for remediation Maxine A. Papadakis, M.D. Professor of Medicine UCSF

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

4. 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

5. Assessment of Professional BehaviorMethods Used in U.S. Medical Schools

6. 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

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

8. 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

9. 2. Diminished capacity for self improvement • Failure to accept constructive criticism • Brusque, hostile or argumentative • Negative or poor attitude • Arrogant • Overconfident • Overly sensitive

10. 3. Relationship with patients • Impaired relationships with patients • Failure to establish rapport • Insensitive to patient needs

11. 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

12. 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?

13. Vignettes

14. 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.

15. 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

16. 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