Remediating Unprofessional Behavior in Medical Students Each School

Remediating Unprofessional Behavior in Medical Students: Each School an Island? By Richard M. Frankel Ph. D. Professor of Medicine and Geriatrics Statewide Professionalism Competency Director Indiana University School of Medicine Director, Walther Center for Palliative Care Research and Education IU/Simon Cancer Center AOA Conference July 1 -2, 2013

Arial view of the IU School of Medicine Indianapolis Campus

Indiana University School of Medicine • Second largest medical school in North America 1, 100 undergraduate students 1, 000 residents 1, 200 full time faculty • Only medical school in Indiana • Nine regional centers around the state

IUSM Competency-based Curriculum: Planning Begun in 1992; Initiated in 19991. Effective Communication 2. Basic Clinical Skills 3. Using Science to Guide Diagnosis, Management, Therapeutics and Prevention 4. Lifelong Learning 5. Self-Awareness, Self-Care, & Personal Growth 6. Social & Community Contexts of Health Care 7. Moral Reasoning & Ethical Judgment 8. Problem Solving 9. Professionalism & Role Recognition

ACGME Competencies (1999, 2005) 1. Patient Care 2. Medical Knowledge 3. Practice-Based Learning and Improvement 4. Interpersonal and Communication Skills 5. Professionalism 6. Systems-Based Practice

Introduced in 1996, Can. MEDS Framework 2005

Professionalism Curriculum at Indiana University • • • White Coat Ceremony – 1 st year ICM I & II Courses – 1 st & 2 nd year Vertical Mentoring Program – throughout all 4 years Intersessions throughout 3 rd year Medicine Clerkship/Surgery Clerkship OSCE’s (3) – cases address various professionalism issues School-wide Grand Rounds on Professionalism Student-initiated Honor Code for IUSM Peer and self-assessment

Professionalism in a Box

“Professionalism doesn’t live in a box, it exists in the life world of the students. ” “I will tell you something about stories They aren’t just entertainment. Don’t be fooled. They are all we have, you see all we have to fight off illness and death. You don’t have anything if you don’t have the stories. ” Leslie Marmon Silko

Competency Management • Nine competency directors plus a chair, each funded from the Dean’s office at 20%-25%, regular meetings as a learning community • Integrated competency/academic grade sheet - competencies grades as P/F • One competency director for all nine competencies at each of the regional campuses • Statewide professionalism team

Competency Structure • All 9 competencies have three levels – Level 1 Intermediate Knowledge and skill (MS 1&2) – Level 2 Proficiency in competencies (MS 3) – Level 3 Advanced knowledge and skills in 3 competencies (MS 4) • Satisfactory progress in academic work and competencies are required to graduate • Two types of competency issues – Competency concern – Isolated deficiency (ID-9)

Competency Pathway Competency concern Course/clerkship director Competency deficiency Competency director Student Promotions Committee

Competency Pathway Cont’d Competency concern Competency deficiency Meet with CD Remediation with CD(s) No formal action taken SPC Dismisses or allows student to continue

Remediation: Challenges and Opportunities

Remediation • • • Overall approach- Advocacy inquiry Evidence from patient interviewing Making an educational diagnosis Designing a remediation plan Follow-up

Case 1 • A second year student came to the school administration concerned about a fellow student’s Facebook posting she had just read which contained an extremely inappropriate “doctor joke”. The posting listed the student’s name and IUSM Class of 2013. The student was concerned that the posting put the school’s reputation in jeopardy given the fact that it was public and anyone could access it.

• After consulting with the dean and competency director, the executive associate dean for education requested that the student in question come before the student promotions committee to “show cause” as to why he should not be dismissed for his actions. • At the hearing the student presented the following letter to the committee which decided to allow him to stay in school providing he successfully remediate his lapse in professionalism

Dear Student Promotions Committee, I have come here today to address you about the unacceptable behavior that I have displayed using my Facebook account. I was clearly not thinking about professionalism and not using sound judgment when I made the post. I express my deepest regrets for offending anyone who has seen this it and realize now that it was very offensive and extremely immature. I certainly understand that this was an extreme lapse of judgment on my part, and take responsibility for my actions. . . I cannot express how devastated I am in myself for doing something that would hurt anyone, especially my classmates, my faculty, or my school’s reputation … I hope that you can accept my deepest apologies for this action, and know that I will do everything I can to regain your trust in me as an upstanding student of this medical school. Matthew Strausburg, Class of 2013

• The Student Promotions Committee recommends that Mr. Strausburg be put on probation and remediate his deficiency with the professionalism competency director. Mr. Strausburg is now sitting in your office to discuss his remediation. What kind of conversation will you have with him and what plans do you have for his remediation?

Please divide into triads and take 5 minutes to discuss how you will go about: • Making an educational diagnosis • Designing a remediation plan

February 4, 2011, Volume 15 Number 5 • Indianapolis, Indiana Reports: I recently posted an offensive and tasteless “doctor joke” for my friends to see on Facebook. Another medical student who viewed it thought the posting was highly unprofessional and put the school in a potentially negative light so brought it to the attention of school administrators. As a result of my actions I was required to make an appearance before the student promotions committee and face the possibility of dismissal for behavior unbecoming a medical student. As a result of this experience I have become acutely aware of the attractions and dangers of social networking and its potential to do harm. Since a case in which a student at Rutgers committed suicide after compromising information about him was circulated on social networking sites I have come to realize that I have a responsibility to recognize that one click of the mouse is all it took to jeopardize my entire future as a physician. —Matthew Strausburg, MS II Class President

Outcomes • Mr. Strausburg volunteers to take part in the MS 1 orientation to the professionalism competency, Indianapolis campus (N=160) • MS 1’s are given his essay to read and critique • Mr. Strausburg is “planted” in the audience without the students’ knowledge • After eliciting student comments, Mr. Strausburg addresses the students and tells his story • In the past 3 years there have been no additional incidents of inappropriate use of social media reported to the school’s administration

Case 2 The clerkship director for OB/GYN has sent you a “heads up” that one of the medical students who has been struggling during the rotation was found cheating on an OB/GYN shelf exam. The Student Promotions Committee has been notified and the chair has asked you to meet with the student before his appearance before the committee. Academic records indicate that this is an excellent student with good grades up until this point. The student is sitting in your office and when asked why he is here, he folds his arms over his chest and says, “I cheated on the OB/GYN exam. ” An uncomfortable silence ensues. How do you proceed?

Fragment of a letter to SPC Every year I make it a habit to visit India in order to see family and friends. Three years ago, I met the person who would become the foundation of my plans and dreams, Tamara. During our very first meeting, I could tell that she was someone special. I had never met anyone who was so soft, gentle, clean-hearted, and had such a zest for life… On July 14 I got a call from India telling me that my fiance had been murdered for no other reason but for the fact that she was of a certain religion. She was visiting Pakistan, was returning home, and was attacked by a man who took objection to the fact that she was not a follower of Allah…

No matter how hard I tried, I couldn’t get rid of the feelings of anger, rage, hopelessness, and guilt along with a constant tightness and chronic pain in my stomach … Toward the end of my ob/gyn clerkship, I found myself avoiding my work, avoiding people, and spending hours at a time in the restroom crying. I questioned everything that I ever believed in, including god. For the 6 days following that dreadful morning, I had little desire to do anything. As I sat for my ob/gyn exam, all I could do was think about her. Before I knew it, my time was running out and I made the poor decision of cheating on my exam, an action that, in the past, I had never even considered and for which I am deeply saddened and sorry.

From: , Albert Sent: Monday, June 06, 2005 6: 10 PM Dear Drs. Frankel and Gaffney: I had my meeting today and the SPC committee has voted to allow me to continue with school! I am extremely happy and feel as if a huge burden has been lifted off of my shoulders. I would just like to thank both of you from the bottom of my heart for everything that you have done for me. You made an extremely difficult situation a whole lot easier to handle. Your understanding and friendly nature was like a breath of fresh air and made me feel extremely comfortable. Once again, thank you for your help, and support. I am eagerly looking forward to this new beginning. Thank you once again! Sincerely, Albert

From: Albert Sent: Thursday, March 15, 2007 2: 45 PM Dear Dr. Frankel, I hope all is well. As you probably know, "match day" was today and I was able to get my first choice. . . IU PM&R! You have always been so kind and generous with your time/advice/suggestions/guidance. Therefore, I wanted to make sure that I write and let you know the results of my match. Thank you so much for all of your help throughout. I could not have reached this point without your guidance. I'm looking forward to starting residency soon! Once again, thank you for everything and take care! Albert

Case 3 The president of the Global Health Student Interest Group has come to you with a defamed poster advertising a lecture by a visiting Indian Professor. She notes that she had seen someone with a white coat in hand writing on the poster but thought the person was taking notes. A few minutes later she noticed that the writing was actually on the poster and was defamatory. Clearly, this is an incident that did not take place in a course or rotation but is nonetheless unprofessional. What will you do to address this issue?

Nov. 1, 2007 BACK TO TOP M&M: Mindfulness in Medicine A Community of Trust and Tolerance? A medical student reported observing a fellow student writing on a poster advertising a lecture, sponsored by the Global Health Student Interest Group, by an American surgeon of Indian extraction who has done a great deal of volunteer work for the poor and indigent in his birth city of Hyderabad. At first it appeared that the person was writing down the information contained on the poster but, upon closer inspection, it was noted that the writing was actually defamatory.

Response: Diversity of opinion is important in any organization, but promoting an atmosphere characterized by respect – a safe and trustworthy place for the exchange of ideas – is a cornerstone of academia. How does it make you, the reader, feel to see this kind of deliberate defamation? What does this incident, and our reaction to it, say about the writer, about us individually, and about our educational community? An incident such as this provides a valuable opportunity for our entire community to reflect on who we want to be and lessons to be learned. We can learn that it is important to encourage diversity of opinion through face-to-face conversations and academic discussion; not in defacing or defaming another's integrity anonymously or surreptitiously…. . Above all, this incident points out the importance of reflecting on the kind of medical school we most want to create and to rededicating ourselves to building a community of trust and tolerance.

May 2, 2009 Part of a reflection sent just before graduation- …I was particularly hurt and offended at this immature act. I immediately took down the flyer and turned it into the Dean’s office. The response from you was overwhelming. Immediate action was taken to inform Department heads of the incident. . It was incredibly reassuring that the School of Medicine would take a student’s concern so seriously and immediately them. I was invited to a meeting with you and members of the Dean’s Office for an open discussion of what had transpired and what measures could be taken to prevent such incidents in the future. Although uneasy at first, I felt reassured that I had done the right thing and was commended for stepping forward. We had an honest dialogue concerning the source of these types of problems, the role of professionalism and tolerance within the school of medicine, and how to use the experience as a learning opportunity for all members of the IUSM community. . .

From this experience, I learned that the medical field is not immune to those people with insensitive or intolerant perspectives, which often affect people in many other environments. Such people undermine the very ideals of teamwork and integrity that are ingrained within us throughout our medical education. That I received such support to address these negative perspectives has motivated me to continue to uphold those positive values to the best of my ability and use incidents such as this as an example on which to build… Although this incident was unfortunate and unpleasant for myself personally, I know that it can serve as a learning opportunity for future students at Indiana University School of Medicine to help develop and enhance their ideals of professionalism in their own careers.

Conclusions • Clearly, the issue of remediation is fundamental to professional formation and currently rests on faculty and administrators who have different philosophies about what it means to be a professional and therefore, different ideas about what to do about behavior that is considered unprofessional. • Research, evidence and dialog are needed to design national standards for what counts as professional behavior and, more importantly, what to do in the short and long run when lapses in professionalism occur. • Situational awareness and active listening skills may be useful in developing remediation programs

While in India, a wise man told me, “After turmoil, one can feel as if there are two animals living in your heart. One animal is the vengeful, angry, violent one. The other animal is the loving, compassionate one. And the one that will win the fight is the one that you feed. ” Albert S.