A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity

Abstract

The relatively new term “Professional Identity Formation” (PIF) complements behavior-based and attitude-based perspectives on professionalism. Unprofessional behavior and its remediation should also be addressed from this perspective. However, a framework is needed to guide discussion and remediation of unprofessional behavior, which can encompass behavior-based, attitude-based, and identity-based perspectives on professionalism. To this end, the authors propose a multi-level professionalism framework which describes, apart from professional behavior, more levels which influence professional performance: environment, competencies, beliefs, values, identity, and mission. The different levels can provide tools for educators to address and discuss unprofessional behavior with their students in a comprehensive way. By reflecting on all the different levels of the framework, educators guard themselves against narrowing the discussion to either professional behavior or professional identity. The multi-level professionalism framework can help educators and students to gain a better understanding of the root of unprofessional behavior, and of remediation strategies that would be appropriate. For despite the recent emphasis on PIF, unprofessional behavior and its remediation will remain important issues in medical education.

Introduction

Unprofessional physician behavior affects patient–doctor relationships as well as patient safety and quality of care (Hickson et al. 2002; Rosenstein 2011, 2015). Interest in professional behavior in medical practice gained momentum when research showed a clear association between unprofessional behavior in undergraduate and postgraduate medical school and unprofessional behavior in later practice (Papadakis et al. 2004, 2005, 2008). This association underscores the importance of addressing unprofessional behavior as early as possible. Although only a small number of students display unprofessional behavior (Mak-van der Vossen et al. 2016; Barnhoorn et al. 2017), unprofessional behavior can harm patients and their trust in the medical profession (Hickson et al. 2002; Rosenstein 2011, 2015; Ellaway et al. 2017). However, assessment and remediation of unprofessional behavior remain difficult tasks (Korszun et al. 2005; Papadakis et al. 2012; Zbieranowski et al. 2013; Bebeau and Faber-Langendoen 2014; Domen 2014; Warren et al. 2014; Barnhoorn and Domen 2015; Ziring et al. 2015; Arnold et al. 2016) (Box 1).

The remediation of unprofessional behavior is hampered by the different perspectives on professionalism and by difficulties in bridging these perspectives (Birden et al. 2014; Irby and Hamstra 2016; Smith et al. 2017). Until recently, two perspectives were prominent in the professionalism discourse. On the one hand, we find a pragmatic, but narrow focus on professional behavior. The focus on behavior, however, has as the advantage that it can be observed and assessed and expectations for desirable behavior can be set relatively easily (Barnhoorn and van Mook 2015). On the other hand, there is a focus on professionalism, referring to character traits, attitudes, virtues and values (van Mook, de Grave, et al. 2009; van Mook, van Luijk, et al. 2009; Barnhoorn and van Mook 2015). This second focus helps to motivate and inspire students, but it is difficult to assess (Barnhoorn and van Mook 2015; Irby and Hamstra 2016).

Box 1 A medical student referred to the professional behavior board.

Case

Sara is a 22-year-old medical student who has been referred to the professional behavior board of her medical school. The brief referral letter mentions a “lack of the right competencies to become a doctor”. A phone call to the referring doctor reveals that her supervisors during the clerkship gynecology have given Sara feedback on “participating too little” or even “being untraceable for parts of the day”. Despite repeated feedback, Sara continued to participate sub standardly? In a meeting with two members of the professional behavior board, Sara asked why she did not act upon the given feedback. She answered: “I try to participate in the clerkships wherever I can. But due to my PhD trajectory I have to spend my time efficiently, so I plan to attend only the parts of the clerkship that are relevant for my future career”.

Both perspectives capture important aspects of the process of becoming a professional physician, but what is missing in both is a broader view on the process of developing into a professional (Holden et al. 2015). The focus, therefore, shifted to the perspective of “Professional Identity Formation” (PIF). PIF can be defined as the process of forming “a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting and feeling like a physician” (Cruess et al. 2014). Each perspective, whether focusing on behavior, attitude (i.e. professionalism) or process (i.e. PIF), has its own strengths and limitations. However, as Sara’s case shows, multiple aspects can play a role at the same time. When discussing and remediating unprofessional behavior, all these aspects must be considered together (Irby and Hamstra 2016).

Several authors have proposed frameworks to address unprofessional behavior that combine elements from the different perspectives on professional behavior (Goldie 2012; Crigger and Godfrey 2014; Cruess, Cruess, Boudreau, et al. 2015; Cruess, Cruess, Steinert, et al. 2015; Irby and Hamstra 2016). The frameworks describe behavior, attitude, and process elements, but none explores the interrelationship between these elements. For a comprehensive understanding of (un)professional behavior, it is necessary to also describe the interrelationships.

Despite calls for comprehensive research in this area, little is still known about best practices in remediation (Hauer et al. 2009; Papadakis et al. 2012; Ziring et al. 2015). Some individual medical schools have published their procedures for identifying and/or remediating unprofessional behavior of medical students and residents (van Mook et al. 2010; Buchanan et al. 2012; Mak-van der Vossen et al. 2013; Domen 2014; Guerrasio et al. 2014; Ziring et al. 2015). Other works have been published on assessment and the organization of remediation (Bebeau and Faber-Langendoen 2014; Arnold et al. 2016). Both the studies on local programs and on assessment and the organization of remediation provide us with useful tips on monitoring student professionalism, assessment methods, and the challenges of organizing remediation. However, in this literature not enough practical guidance is provided for the remediation of individuals who display unprofessional behavior.

A comprehensive framework is needed to discuss unprofessional behavior beyond the perspective of either behavior, attitude, or process (Boileau et al. 2017). The absence of such a framework feeds the perception of teachers that they are ill-equipped to address unprofessional behavior effectively. This in turn may lead to delays in, or lack of remediation (Boileau et al. 2017). In this article, we propose a comprehensive approach to guide the remediation of unprofessional behavior: the multi-level professionalism framework. This framework is an adaptation of the levels of change model Korthagen developed for teacher training (Korthagen 2004).

The multi-level professionalism framework

We expect the multi-level professionalism framework to be of value for various professions, in particular for the medical profession, and medical education, as it can serve as a framework for reflection and development. Korthagen developed a model consisting of six levels: environment, behavior, competencies, beliefs, identity, and, at the model’s center, mission (Korthagen 2004). The model shows that the essential qualities of a good teacher should not only be described in terms of behavior or competencies; more aspects should be taken into account. Competencies, for example can be seen as potential for behavior, but which competencies will be put into practice and how depends on the environment (Korthagen 2004). What happens on the outer levels of the model influences the inner levels and vice versa.

We have adapted this model into a framework for the medical context. Below we describe the levels of the multi-level professionalism framework (see Figure 1), and elaborate on its usefulness to medical education. We expect that this framework will help teachers and students to reflect on professionalism at all levels in the case of unprofessional behavior.

Figure 1. The multi-level professionalism framework.

Environment: Where am I?

The environment level refers to the diverse contexts in which the medical student lives, works and learns, and which influence his or her behavior. Within the realm of medical education, it describes the academic learning environment: both the hidden and the formal curriculum, as well as the clinical, patient-related environment (Hafferty 1998; Franco et al. 2017; Hawick et al. 2017). The personal environment of the student refers to his or her personal life and circumstances, such as problems at home, physical or mental illness and personal history (Mak-van der Vossen et al. 2016). These influence the student’s behavior and development. Therefore, the environment can also have a profound influence on a student’s professional performance, both in a limiting and an expanding way. Student behavior can only be understood when the context, i.e. the environment is included in the interpretation (Korthagen 2004; Jha et al. 2016; Franco et al. 2017; Mason 2017).

Behavior: What am I doing?

The focal point at the behavioral level is the performance of the student, which can be directly observed and assessed. Behavior attracts much attention, because it is at this level that actual patient encounters take place, as well as encounters between students and faculty, and students and peers. Apart from the environment, behavior is motivated by various forces within the person, which are represented in the inner circles of the framework.

Competencies: What can I do?

Competencies can be defined as an integrated body of knowledge, skills, and attitudes (Stoof et al. 2002) that make professional behavior possible. They have gained a strong basis in medical education (Hunderfund et al. 2017). Likewise, professionalism programs are often formulated in terms of competencies (Royal College of Physicians and Surgeons in Canada 2017). Competencies are closely connected to behavior, they represent a potential for behavior. However, whether competencies are put into practice depends, among other things, on the circumstances or environment, and on underlying beliefs, values, identity, and mission. Students need to reflect on when and how to put their competencies into practice, in order to be able to match their behavior to the situation at hand.

Beliefs and values: What do I believe in?

The level of beliefs and values deals with the conceptions and convictions a medical student holds true regarding the medical profession and his or her place in it. For instance, students can adopt a disease-focused belief or a more patient-focused belief. The beliefs students hold influence a student’s motivation to develop certain competencies: If a student believes that the main role of the medical professional to be curing disease, there will be a tendency to focus on developing technical competencies. If a student instead believes caring for patients is central to medicine, a strong motivation to develop communication competencies can be expected. However, also the other way around, behavior and competencies influence student’s beliefs. For example developing communication competencies does not only make the student’s interviewing style more effective, it may also alter underlying beliefs about communication, for instance that it is not only about being warm and empathetic, but also that in some instances in medical care communication may be more effective than prescribing pills or operating (Jenkins and Fallowfield 2002).

Identity: Who am I?

Identity can be described as the way one defines oneself in terms of characteristics, values, and norms, including the characteristics, values, and norms of the profession (Korthagen 2004; Cruess et al. 2014). The more students learn about themselves, for example by reflecting on questions such as “who am I?” and “what kind of doctor do I want to be?”, the more they are aware of how their identity influences their behavior. A detailed guide for the assessment of identity has been provided by Bebeau and Faber-Langendoen (2014).

Mission: Why do I do what I do?

The question here is what moves a student to do what he or she does. The mission level is about answers to highly personal questions, such as “to what end do I want to become a doctor?” and “what is my personal calling as a doctor?”. According to Korthagen, this level describes people’s driving force; what is it deep inside us that move to do what we do. It gives meaning to one’s own existence within a larger whole (Korthagen 2004). The mission level differs from the identity level in that refers to medical students’ self-image, whereas the mission level is about what role the medical student sees for him- or her-self in relation to others.

Applying the multi-level professionalism framework to remediation

We now revisit the case in order to explore how the multi-level professionalism framework can help medical educators to support students in developing professional behavior. The brief history already reveals three levels on which we can discuss Sara’s professional performance: behavior, competencies, and beliefs (Box 2).

Box 2 The multi-level professionalism framework applied to Sara’s case.

The case revisited 1

Sara’s behavior (her lack of participation) was not appreciated by her teachers. By stating that she lacks the right competencies for a future doctor, the referring doctor implies there is such thing as the “right competencies for a future doctor”. Sara, however, believes she does not need to participate in every part of the clerkship, knowing already where she is heading.

Having taken note of the referral letter and the additional explanation by the referring doctor, Sara is required to discuss her professional performance with two members of the professional behavior board. This discussion will be structured using the multi-level professionalism framework (Box 3).

Box 3 Discussing Sara’s professional performance at levels of the multi-level professionalism framework.

The case revisited 2

The board first needed to reach consensus with Sara about the behavior that has been labeled as unprofessional. Sara agrees that large parts of most clerkships do not interest her, and that, when she can be missed, she works on her PhD trajectory in ophthalmology. Concerning the environment, Sara says that several specialists, in their lectures during her pre-clinical years, as well as supervisors during some clerkship stressed the importance of focus in order to reach the top. She lives by her motto: “If you have a goal, stick to it!” Besides, Sara thinks she already possesses the basic competencies needed to become a good doctor. She says she shares the belief that most of the clerkships, for her, are redundant. After all, she already knows what she wants to become and believes that she better spend her time on her PhD trajectory. Ultimately, the board wanted to talk to Sara about her professional identity. Sara’s answer to the question “what kind of doctor do you want to become?” is that she wants to reach the absolute top in ophthalmology. At the level of mission, when asked “why do you want to become a top ophthalmologist?”, Sara states that the societal status of a super-specialist appeals to her and that the practical and technical aspects of ophthalmology are the main reasons for her preference.

In discussing Sara’s professional performance by asking the questions above at the different levels of the multi-level professionalism framework, the board aimed to enhance Sara’s reflection process. The board’s next step is remediation. In this phase, appropriate interventions are discussed, aimed at Sara adjusting her behavior. In Sara’s case, the board could have her participate in an outpatient clinic for a week, supervised by a holistic working ophthalmologist who is both technically skilled and empathic. After talking to this ophthalmologist, Sara would be instructed to write a reflection assignment describing how she was challenged at the several levels of the multi-level professionalism framework while seeing this ophthalmologist at work. Her reflection would serve as a basis for a next session in which the board could get a clear picture of the progress of Sara’s professional development.

Discussion

The recent proposal to change the goals of medical education from teaching and assessing professionalism to the formation of a professional identity also has implications for how unprofessional behavior will be addressed (Cruess et al. 2014). Remediation of unprofessional behavior can be approached differently, but will remain challenging (Bebeau and Faber-Langendoen 2014; Arnold et al. 2016). Each of the prevailing perspectives on professionalism, whether behavior-, attitude-, or process-based, views unprofessional behavior differently, and consequently, different remediation strategies are recommended (Irby and Hamstra 2016). However, bridging the various perspectives on professionalism may make remediation more efficient and more effective.

From the behavior-based perspective, the goal of medical education is to deliver competent doctors to society who behaves professionally. Behavior is seen as measurable, and if behavior of a medical student is judged as unprofessional, remediation is applied. This often involves identifying behavior, discussing behavior, developing a remediation plan, monitoring compliance to the remediation plan and sometimes includes probation, or the dismissal of the student (Domen 2014; Irby and Hamstra 2016; Barnhoorn et al. 2017). From the attitude-based perspective, the goal of medical education is fostering the virtues and values needed for good medical practice. Virtues and values are difficult to measure. In case of unprofessional behavior, remediation involves reflection assignments and feedback (Irby and Hamstra 2016). From the process-based perspective, a goal of medical education is the formation of a professional identity (Cruess et al. 2014). This professional identity is achieved over time, in stages (Cruess et al. 2014). Unprofessional behavior can be seen as a failure to progress to the next developmental stage. According to this perspective, remediation must be tailored to the developmental stages, and involves helping students, continuously and over a long period of time, “to find out who they are, who they are becoming and who they wish to become” (Cruess et al. 2014).

All of these perspectives illuminate professionalism from a different viewpoint, and all are needed, as they have their own strengths and limitations. A comprehensive framework like the multi-level professionalism framework in which all these perspectives get a share can also guide remediation of unprofessional behavior beyond the sole perspective of either behavior, attitude, or process.

The multi-level professionalism framework, however, is not unique in linking different perspectives on professionalism. Cruess et al. have linked the behavior-based perspective to the PIF-perspective in Miller’s “Amended Pyramid” (Cruess, Cruess, Steinert, et al. 2015). In addition to the original pyramid, they propose an extra level of “thinking, acting and feeling like a physician” (“Is”) at the apex of the pyramid (Cruess, Cruess, Steinert, et al. 2015). Presented as an assessment tool for professional identity, they suggest that the model helps in creating a perspective on assessment of PIF (Cruess et al. 2016). However, it does not provide tools for educators to address unprofessional behavior. The proposed multi-level professionalism framework, on the other hand, describes the nonhierarchical interplay between the different levels relevant to professionalism.

Bebeau also links the behavior-based perspective to the PIF-based perspective by providing a diagnostic assessment of strengths and shortcomings in students’ understanding of the ethical and moral dimensions of professionalism (Bebeau and Faber-Langendoen 2014). However, it does not provide a clear focus for individual remediation. The multi-level professionalism framework offers a practical guidance for the remediation which bridges the various perspectives on professionalism.

Working with the multi-level professionalism requires highly skilled remediators. Proficient faculty members must be chosen for the challenging job of remediation, and remediators must be offered continuous development opportunities in coaching, direct observation, and feedback skills (Kalet et al. 2016). Resources to conduct this work (i.e. time and money) need to be allocated for this (Kalet et al. 2016).

The multi-level professionalism framework neither pretends to denote a blueprint for professionalism, nor pretends to capture the “essence” of professionalism. Addressing the important perspectives in professionalism, it invites students and teachers to reflect on more than just the level of behavior itself. Working with the framework suggests that deeper learning can be attained. Further research is needed to confirm the added value of the multi-level professionalism framework in medical education.

Conclusions

Despite the recent emphasis on PIF, a focus on unprofessional behavior and its remediation will remain vitally important for medical education. However, this literature does not provide a practical remediation framework which reflects the different perspectives on professionalism. The multi-level professionalism framework can serve as a comprehensive framework to guide the remediation of individual unprofessional behavior. Moreover, by using the multi-level professionalism framework, the user is urged to reflect on different perspectives on professionalism with the purpose of supporting PIF.

Practice points

• Professional Identity Formation (PIF) is a relatively new, process-based perspective on professionalism.

• From this process-based perspective, an important goal of medical education is the formation of a professional identity.

• The PIF-based perspective complements the behavior-based and attitude-based perspectives on professionalism.

• There is a need for a comprehensive yet practical framework to address individual unprofessional behavior beyond the perspective of behavior, attitude, or process.

• The multi-level professionalism framework can serve as a comprehensive framework to guide the remediation of unprofessional behavior, by encouraging reflection on all-important levels that influence professionalism.

Glossary

Professional Behavior: Placing the best interests of patients at the center of everything you do (Barnhoorn and Youngson 2014, Med Teach).

Remediation: The process of facilitating corrections for physicians and trainees who are not on course to competence or a professional identity.

Notes on contributors

Pieter C. Barnhoorn, MD, is a PhD Candidate in General Practice at Leiden University Medical Center, Leiden, The Netherlands.

Mirjam Houtlosser, PhD, is an Associate Professor in Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands.

Marleen W. Ottenhoff-de Jonge, MD, is an Associate Professor in General Practice at Leiden University Medical Center, Leiden, The Netherlands.

Geurt T. J. M. Essers, MSc, PhD, is an Associate Professor in Medical Education at The Netherlands’ Network of the GP Specialty Training Institutes, Utrecht, The Netherlands.

Mattijs E. Numans, MD, PhD, is a Professor in General Practice at Leiden University Medical Center, Leiden, The Netherlands.

Anneke W. M. Kramer, MD, PhD, is a Professor in Medical Education at Leiden University Medical Center, Leiden, The Netherlands.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.