Medical student behavior: A sign of things to come?
Should professionalism be required to graduate?
When hiring new physicians, health care practices might want to look beyond grade transcripts, according to a medical school professor in California who has determined that medical students who were disciplined in school for irresponsible attendance or patient care are nearly nine times more likely to be disciplined by their medical boards when they become practicing physicians.
Or, to look at it another way, physicians disciplined by state medical boards were three times more likely than their colleagues to have exhibited unprofessional behavior while in medical school.
"These data support the growing movement to make the demonstration of professional behavior a requirement for graduation from medical school in the United States," says Maxine A. Papadakis, MD, professor of clinical medicine at the University of California at San Francisco and associate dean of student affairs at UCSF School of Medicine. "It is one way that we can improve health care quality by focusing on human factors that ultimately affect physician performance."
Papadakis led a team of researchers who looked at hundreds of cases of physicians disciplined by state medical boards, and compared their behavior as practicing physicians to their conduct as medical students. Papadakis, lead author of the report that appeared in the New England Journal of Medicine in December 2005, says the findings may help identify and correct behaviors while doctors are still in training.
The researchers looked for early warning signs during medical school that were associated with a higher risk for disciplinary action when the students became practicing physicians.
Behavior for which physicians were disciplined included use of drugs or alcohol, unprofessional conduct, conviction for a crime, and negligence. Unprofessional behavior in medical school was the strongest risk factor for later disciplinary action by a state medical board. In contrast, more traditional measures of academic success, such as performance on the Medical College Admission Test and early medical school grades, were much weaker risk factors for later disciplinary action, according to the study.
Papadakis cautions that because the study is retrospective, it is not predictive of future behavior of current medical school students. "However, we have at least established a risk factor for disciplinary action against practicing physicians," she points out.
This is the first national study that links performance in medical school with later disciplinary action, and, therefore, with a potential threat to patient safety, according to Papadakis.
The study included 235 graduates since 1970 of three medical schools — UCSF School of Medicine, University of Michigan Medical School in Ann Arbor, and Jefferson Medical College of Thomas Jefferson University in Philadelphia — who were disciplined by one of 40 state medical boards between 1990 and 2003. They were matched with 469 control physicians according to medical school and graduation year.
"We looked at these three schools because they’re geographically diverse, represent both public and private institutions, and have very thorough records of their own students," explains Papadakis.
The study looked at a broad range of unprofessional behaviors in medical students. The strongest association with disciplinary action was seen in students who were irresponsible in attendance or patient care. These students were nearly nine times more likely than their colleagues to be disciplined when they became practicing physicians.
Graduation contingent on professionalism?
Papadakis found that of former UCSF medical students who had faced disciplinary action by the Medical Board of California between 1990 and 2000, 95% of the 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.
"Professionalism can and must be taught in medical school," notes the study report. As part of this, the study recommends that medical school admissions and graduation standards be reviewed to make sure they contain explicit language about professional behavior and that professionalism should be an important part of the curriculum. It also recommends that standardized methods be implemented for both assessing the personal qualities of medical school applicants and predicting their performance.
Papadakis emphasizes the importance of early identification and remediation of unprofessional behavior among medical students. "We want to identify people who have trouble in this domain as early as possible," she explains. "We all grow up, and most of us become more professional as we mature. However, for the rare student who cannot demonstrate professional behavior, we need to think long and hard about whether he or she should graduate from medical school."
Papadakis noted the collaborative nature of the research, saying, "This study brings together the licensing and disciplinary branch of the medical system, represented by the Federation of State Medical Boards, with the medical schools, so that we can all help patients in the long run."
Schools already making 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 report," in which two or three reports on a single student prompt a close tracking of the student’s behavior and potential disciplinary action.
Professionalism-related efforts used by other schools include lectures on ethics, small group work on professionalism topics, standardized patient exercises that include ethical and professionalism components, and coursework that promotes reflection on professional behavior.
Papadakis urges educators to place as much emphasis on professionalism as they do on other academic competencies.
"Most physicians take great pride in their professionalism and this is a quality that must be cherished," Papadakis stresses. "Our study shows that the tradition of professionalism must begin in medical school and that standards for professionalism in students are as important, or perhaps more important, than other measures of success."
Source
- Maxine A. Papadakis, MD, professor of clinical medicine, University of California at San Francisco; associate dean of student affairs, UCSF School of Medicine. E-mail: [email protected].
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