The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 8

Topics in Training | April 18, 2012

Teaching Professionalism in Orthopaedic Surgery Residency Programs

Joseph D. Zuckerman, MD¹; Justin P. Holder, BA¹; John J. Mercuri, BS, MA¹; Donna P. Phillips, MD¹; Kenneth A. Egol, MD¹

¹ Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, 14th Floor, New York, NY 10003. E-mail address for J.D. Zuckerman: joseph.zuckerman@ nyumc.org

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J Bone Joint Surg Am, 2012 Apr 18;94(8):e51 1-7. doi: 10.2106/JBJS.K.00504

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Professionalism is difficult to define, to measure, and to teach. The word derives from the Latin verb profiteri, which means “to declare publicly.”¹ This etymology embodies the dual nature of professionalism as a personal quality and an active behavior. Professionals must publicly declare the ideals to which they commit themselves and then expect that the public will hold them accountable for meeting those ideals. Members of a profession are also entrusted with the responsibility to educate and self-regulate its members. This paper will review the teaching and assessment of professionalism in orthopaedic surgery residency training.

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Introduction

Defining Professionalism

Several fields of medicine have defined professionalism. The American Academy of Pediatrics identified honesty and integrity, reliability, responsibility, respect for others, self-improvement, compassion and empathy, communication, collaboration, self-awareness, and altruism as professionalism's central components². The American Board of Internal Medicine, the European Federation of Internal Medicine, and the American College of Physicians (ACP) developed three principles and ten responsibilities of the medical professional. The “principles” are the primacy of patient welfare, patient autonomy, and social justice. Some of the “responsibilities” are commitments to ideals such as honesty, confidentiality, access to care, and trust³.

Some have taken a philosophical approach to defining professionalism. For example, DeRosa proposed that professionalism is a moral undertaking that requires commitment to virtues such as fidelity, trust, benevolence, intellectual honesty, courage, compassion, and truthfulness⁴. Baldwin and Bunch built on work by psychologists and proposed that professionalism is a developmental process in which individuals progress from an awareness of, and sensitivity to, professionalism to actual professional conduct⁵. Christian et al. suggested that professionalism is grounded in altruism, or putting another's interests ahead of one's own⁶.

Given the difficulty of defining professionalism, The Accreditation Council for Graduate Medical Education (ACGME) has instead described what is expected of a professional resident. A resident must demonstrate a “commitment to carrying out professional responsibilities and an adherence to ethical principles.” Specifically, residents must exhibit “compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; and sensitivity and responsiveness to a diverse patient population.”⁷

Two of the ACP's principles, autonomy and social justice, deserve further discussion. Autonomy is the right of people who are making decisions that define their lives to make the decisions for themselves, according to their values, and in dialogue with their society^8-10. An autonomous person must have the capacity to understand information and communicate a choice; “to use that information in a process of reasoning and deliberation;” and “to entertain at once or serially, and to compare the consequences of, alternative choices or courses of action.”⁹ Rawls defined social justice as “fairness.” Rawls did not equate these concepts literally; rather, he argued that the “principles of social justice” should be the result of “a fair agreement or bargain.”¹¹ With regard to limited health care resources, this formulation of social justice requires that all patients be treated in the same manner and provided with equal access to “an adequate level of healthcare that fulfills basic needs.”⁸

The interplay between autonomy, social justice, and professionalism is complex. For example, surgeons respect autonomy by personally obtaining informed consent from their patients, not by abdicating this responsibility to a junior member of the team. One should strive to meet this ideal in every patient despite the various barriers in clinical practice. Similarly, the two-tiered health insurance system (i.e., insured and uninsured; private and public) that exists at virtually every health care institution has created a structural injustice in which uninsured or publicly insured patients are treated in resident-run, faculty-supervised clinics while insured patients are treated in faculty offices. Maintaining professionalism in the face of such challenges requires a concerted effort from the physician.

Most definitions of professionalism approach the concept analytically by deconstructing the idea into component parts¹². With a concept such as professionalism, however, it is difficult to capture all components and to explain their interrelatedness. Therefore, we endorse a synthetic definition of professionalism described by Pellegrino, who writes that professionalism involves both a promise of help to the vulnerable patient and a promise of expertise in the field^1,13. Pangaro notes that all individual attributes of analytic definitions are encompassed by this powerful, two-part promise¹². Pellegrino's synthetic definition recognizes that a professional must be simultaneously expert in all component areas of the analytic definitions. Furthermore, a publicly declared promise made in the context of the physician-patient relationship is consistent with the etymology of professionalism¹⁴.

Professionalism in Orthopaedic Surgery

Ethical issues have emerged that jeopardize the integrity of orthopaedic surgeons’ professional behavior in the contemporary health care setting. For example, both orthopaedic surgeons and hospitals depend on industry to provide supplies, implants, pharmaceuticals, and other items required for patient care. This reliance on third parties creates conflicts between physicians and hospitals regarding the costs and availability of resources.

Since orthopaedic surgeons use an array of instruments and implants, a codependency develops between the surgeons and the manufacturing companies and their representatives who supply these devices. Frequently, surgeons work closely with companies to assist in the design and development of implants. These relationships often involve formal agreements with specific terms for remuneration to the surgeons for their time and expertise.

Changes in technology, increases in surgical costs, and decreasing reimbursements may alter the dynamic between orthopaedic surgeons, industry, and patients. These factors not only threaten the surgeon's decision-making independence and objectivity, but they also undermine the foundational patient-physician relationship^15,16. The compromise of this central tenet of medical practice provides further support for the importance of teaching and assessing professionalism in residency training.

Relationships between surgeons and industry impact the teaching of professionalism in residency programs. Consider the example outlined in Table I. This faculty member was considered an excellent clinical educator; however, he exhibited unprofessional behavior that should not be modeled by residents. The 2007 settlements between the Department of Justice and orthopaedic device manufacturers elucidated many physician-industry relationships that were improperly disclosed. The impact of these settlements on orthopaedic residents should not be underestimated. Residents frequently model the behavior of faculty, and this type of unprofessional behavior at any level of training or practice undermines the teaching of professionalism in training programs.

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TABLE I Example of Unprofessional Faculty Behavior

Failure to Disclose
A faculty member is a “consultant” for an orthopaedic manufacturing company, and he receives $250,000 per year for services performed. However, the nature of this relationship has not been disclosed to the Department Chair, and the faculty member has not updated his faculty disclosure documents. When the company is required to disclose its consultants, the university identifies the discrepancy. An investigation is performed, and it is discovered that the faculty member did not disclose his consulting work on conflict-of-interest documents submitted to the institutional review board (IRB). The faculty member is censured, placed on probation, and prohibited from participating in any research requiring IRB approval for twenty-four months.

Failure to Disclose

A faculty member is a “consultant” for an orthopaedic manufacturing company, and he receives $250,000 per year for services performed. However, the nature of this relationship has not been disclosed to the Department Chair, and the faculty member has not updated his faculty disclosure documents. When the company is required to disclose its consultants, the university identifies the discrepancy. An investigation is performed, and it is discovered that the faculty member did not disclose his consulting work on conflict-of-interest documents submitted to the institutional review board (IRB). The faculty member is censured, placed on probation, and prohibited from participating in any research requiring IRB approval for twenty-four months.

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TABLE I Example of Unprofessional Faculty Behavior

Failure to Disclose
A faculty member is a “consultant” for an orthopaedic manufacturing company, and he receives $250,000 per year for services performed. However, the nature of this relationship has not been disclosed to the Department Chair, and the faculty member has not updated his faculty disclosure documents. When the company is required to disclose its consultants, the university identifies the discrepancy. An investigation is performed, and it is discovered that the faculty member did not disclose his consulting work on conflict-of-interest documents submitted to the institutional review board (IRB). The faculty member is censured, placed on probation, and prohibited from participating in any research requiring IRB approval for twenty-four months.

Failure to Disclose

The ACGME notes that professional physicians adhere to ethical principles⁷. Adhering to such principles requires strong moral judgment. Huddle even described professionalism as a type of “medical morality.”¹⁷ This recognition is important to orthopaedic surgery, as highlighted by the research of Baldwin and Bunch using the Defining Issues Test to describe the moral reasoning of orthopaedic surgeons. Despite the seeming homogeneity of the specialty, orthopaedic surgeons varied in their moral reasoning; the lowest quintile of surgeons reasoned morally at or below the level of high school seniors, whereas only the top quintile reasoned at the level of an individual who had finished graduate school⁵. Furthermore, a study that incorporated malpractice claim data found that orthopaedic surgeons with fewer than 0.20 claims per year demonstrated significantly more sophisticated moral reasoning than surgeons with more than 0.40 claims per year¹⁸.

Clearly, it is essential that orthopaedic residency programs make the teaching of professionalism and medical ethics as important as the acquisition of a fund of orthopaedic knowledge and operative skill. However, although there may be little disagreement that teaching and assessing professionalism in residency are necessary, the best methods for accomplishing this task have not been clearly defined.

Methods of Teaching Professionalism

Teaching professionalism requires formal curricula that foster professional attitudes and behaviors in productive learning environments³. The historic approach of teaching professionalism through emulation is necessary but insufficient, especially when faculty members model poor behaviors and residents lack professional mentors. Therefore, graduate medical education (GME) programs must constantly improve their formalized curricula. Residency training is a critical time in a physician's professional development. It is a time when new physicians are given important specialty-specific responsibilities that influence the attitudes, behaviors, and beliefs that they employ throughout their careers. For example, resident work hour limitations require that residents share the responsibilities of patient care. They must now acquire skills for team-based care and the sharing of patient information¹⁹.

Finding successful and comprehensive methods of teaching professionalism is challenging because of the concept's abstract nature. Clearly, teaching professionalism is not as concrete as teaching residents to perform surgical procedures. Some even argue that professionalism cannot be taught and measured as suggested by the ACGME because it is a preexisting aspect of the trainee's personal identity and character that must be developed¹⁷. If these character traits are preexisting, then medical schools and residency programs may wish to screen applicants for the foundations of professional identity. Unfortunately, student professionalism is difficult to quantify in a way that benefits admissions committees²⁰. Research performed in collaboration with other academic disciplines such as psychology is needed to develop tools that can positively impact the selection process. Also, it is advantageous to consider medical school and residency training as a continuum in which medical and residency educators work closely to develop programs in professionalism education.

There are certainly effective formal and informal methods that can be used by residency programs to teach and develop professionalism as a part of the curriculum (Table II). A lecture series is one way to present the core tenets of professionalism to residents. These lectures should present communication skills such as gathering and interpreting information, counseling patients, and developing relationships with colleagues, patients, and families. Lecturers should discuss the influence that physicians have over patients. Surgeons who are unaware of unintended intimidation may be unable to establish constructive relationships, obtain accurate information, and facilitate shared decision-making. Other lecture topics should include issues that residents frequently face, such as making difficult treatment decisions and dealing with challenging patients and families. Delivering bad news is yet another competency that is difficult to master, and residents should learn how to handle their emotions, to prepare patients and assess their readiness, and to deliver the information. Surgical residents also have to work as a team with other medical staff, and they should have a clear understanding of interdisciplinary respect, accountability, and decision-making. Finally, residents must understand how to treat patients from various cultural backgrounds by overcoming language barriers and managing informed consent issues. The Department of Surgery at the New York University School of Medicine developed a curriculum that addressed many of these topics, including self-awareness of personal and professional goals. They used interactive seminars and group discussions with surgical residents and attending physicians to supplement lectures, with an overall emphasis on the principles of patient-physician communication. This approach was shown to be successful for teaching critical professional competencies²¹.

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TABLE II Methods of Teaching and Assessing Professionalism in Orthopaedic Surgery Residency Programs

Teaching	Assessment
Active	360-degree assessments
Lecture series	Performance-based evaluations
Studying the history of the field	Global performance ratings
Case discussions	Self-evaluation of performance
Video vignettes	Evaluation of professionalism portfolio
Working with diverse populations	Objective structured clinical examinations
Mentoring programs	Unannounced standardized patients
Critical incident reports	Critical incident reports
Portfolio learning	Evaluation of ethics knowledge
Passive
“Hidden curriculum”

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TABLE II Methods of Teaching and Assessing Professionalism in Orthopaedic Surgery Residency Programs

Teaching	Assessment
Active	360-degree assessments
Lecture series	Performance-based evaluations
Studying the history of the field	Global performance ratings
Case discussions	Self-evaluation of performance
Video vignettes	Evaluation of professionalism portfolio
Working with diverse populations	Objective structured clinical examinations
Mentoring programs	Unannounced standardized patients
Critical incident reports	Critical incident reports
Portfolio learning	Evaluation of ethics knowledge
Passive
“Hidden curriculum”

There is also value in residents learning about the history of their profession through presentations and articles devoted to the “classics” of the field. Residents must understand that the focus on professionalism is not merely the result of its designation as an ACGME competency. The 1910 Flexner Report deplored medical schools that graduated poorly trained and unprofessional students¹⁴. Similarly, many of the foundational figures of modern medicine, especially William Osler, wrote and spoke extensively about the central importance of professionalism, humanism, and the physician-patient relationship. Encouraging professionalism through historical awareness has been used successfully in anesthesiology and has applicability to orthopaedic surgery²². Learning and understanding the historical context of the field provide residents with a greater appreciation of the legacy that they are continuing. This increased dignity and solidarity may motivate residents to behave professionally.

Whatever is taught in the classroom should be reinforced and applied outside it. Case discussions are a method of teaching professionalism and applying ethical principles to clinical practice. These discussions can be generated by faculty or by residents. Faculty-generated discussions are easier to facilitate and less time-consuming because they can be repeated with different groups of residents. However, resident-generated discussions of cases focus on patients with whom the residents are personally involved. The residents’ personal experiences make these cases poignant, and residents value the ability to put what they have learned in a discussion into practice immediately²³. The truism that residents learn best from hands-on experience rings true in this context. When residents are required to prepare a case discussion on a specific issue of professionalism regarding one of their patients, it is often a lesson that is learned for life. Moreover, discussing these cases in an open forum has several benefits. For example, the institution will have the opportunity to publicly demonstrate its commitment to professionalism, the residents will learn that constructive discussions about unprofessional behavior are encouraged and valued, and all members of the institution will have the opportunity to learn from each other's experiences.

Video vignettes can also be used to teach core ethical and professional values. These vignettes are brief videotapes of hypothetical encounters among patients, families, and physicians in various clinical settings that are modeled after actual clinical cases and situations. The scripted nature of these films allows for the inclusion of examples of poor professional behavior. They also allow educators to act out challenging patient-physician interactions for residents to analyze. The vignettes can be used as a stimulus for a discussion in which the instructor should make certain that each resident participates²⁴. The American Academy of Orthopaedic Surgeons (AAOS) has produced a series of ten video vignettes that demonstrate situations related to ethical behavior and professionalism. Residency programs are encouraged to use the vignettes as a form of small group instruction^25,26.

Communicating with patients from different cultural backgrounds is challenging to residents because of differences in values and language. Residency training should include rotations to hospitals that serve indigent patients. These rotations offer exposure to cultural, ethnic, and language differences. Traveling abroad represents another opportunity for residents to develop their professional activities and behaviors. Immersing oneself in an underprivileged society and working in a medically underserved community can help residents to broaden their appreciation of different cultures. Residency programs that offer electives or short-term volunteer opportunities in impoverished foreign areas provide their residents with a valuable opportunity for professional development.

Approximately ten years ago, the AAOS developed a Communications Skills Mentoring Program in conjunction with the Institute for Healthcare Communication. Historically, orthopaedic surgeons were perceived as “high tech and low touch.” The goal of this program was to foster a “high touch” persona by enhancing the communication skills of orthopaedic surgeons. Additional goals were improved diagnostic accuracy, improved satisfaction of patients and clinicians, decreased malpractice claims, better adherence to treatment plans, and better clinical outcomes. Although the workshops do not specifically address professionalism, professional surgeons must have excellent communication skills. Since the program's launch, the AAOS has trained over one hundred mentors, and over five thousand orthopaedic surgeons and residents have participated. Subsequent patient surveys have demonstrated the impact of this program. Orthopaedic surgeons are now perceived much more favorably with regard to their communication skills²⁷.

What is unintentionally taught to residents is just as important as the formal curriculum. A “hidden curriculum” exists in which attending physicians transmit their beliefs, attitudes, and behaviors to residents through everyday interactions. The importance of these interactions cannot be overemphasized. Residency training is a socialization process in which trainees frequently adopt the attitudes and behaviors of their superiors. Generally, the hidden curriculum helps residents to gain an understanding of clinical practice and to learn to translate their abstract knowledge and skills into practice. Indeed, they learn many of their technical skills, communication skills, and behaviors from their daily interactions with faculty members. Faculty must therefore be aware of the impact of their daily comments and actions to ensure that professional behavior is taught properly²⁸.

Unfortunately, there can be a disparity in content and emphasis between what residents are formally taught and the values they observe in practice. As mentioned earlier, faculty who distance themselves from the informed consent process demonstrate to residents that a respect for shared decision-making is nothing more than a token gesture. Faculty must ensure that they serve as suitable role models for residents and impart the correct moral attitudes and behaviors through their daily interactions²⁹. In this context, participation of the faculty in the professionalism curriculum should be emphasized to reinforce the performance and conduct expected of the residents³⁰. Furthermore, orthopaedic surgery educators should propose creative solutions to the economic, medicolegal, and other concerns that encourage a socially unjust, two-tiered system of medical care.

Finally, it is important to note that the teaching and development of professionalism begins during medical school. Many of the approaches described in this section are currently used in or readily applicable to undergraduate medical education^31-35. Moreover, the Association of American Medical Colleges has described professionalism as an important learning objective in medical student education, much as the ACGME has described professionalism as a core competency for resident physicians^36,37. In order to facilitate the most effective professionalism curricula for medical students, residency programs should work closely with affiliated medical schools to articulate what is expected of professional interns and residents.

Assessment of Professionalism

Residency training programs must assess resident performance in all ACGME core competencies, including professionalism. Although professionalism is more difficult to evaluate than the other competencies, it is equally important by virtue of its global impact on how the resident will practice. Assessment is also necessary because it motivates residents to learn important skills and it helps to determine whether professional values have been adequately understood. Assessment is, therefore, a form of learning in itself.

Several techniques can assist in quantitatively and qualitatively evaluating resident professionalism (Table II). One technique is the 360-degree assessment, in which staff members such as nurses, social workers, and case managers evaluate residents’ interactions. Such assessments should be compared with performance-based evaluations from patients, peers, superiors, and other members of the medical staff. It is common for residents’ interactions with members of the faculty to differ from their interactions with their peers or hospital staff. These disparate evaluations can be incorporated into global performance ratings, in which an individual's overall performance is summarized and feedback is provided. Professionalism must be longitudinally assessed since it changes over the course of residency training. Professionalism is also context-dependent, so residents must have multiple opportunities to demonstrate their capabilities, and a variety of observers are needed³⁸. Residents should also evaluate their own performance, and reflective writing on personal experiences and observations, combined with self-evaluations, can be included in a professionalism portfolio³⁹.

A professionalism portfolio is a valuable tool for assessment and learning. A portfolio is a compilation of work that provides direct evidence of competency in certain areas⁴⁰. Resident-generated portfolios have been used successfully in psychiatry GME programs to demonstrate competence in five of the six ACGME domains, including professionalism⁴¹. Residents were asked to draw from personal encounters with real patients and to write entries regarding several different aspects of psychiatric care. Faculty members then evaluated the entries for evidence of the six competencies. Professionalism portfolios should include a wide variety of materials such as 360-degree evaluations, critical incident reports, written narratives about patient care experiences, and reflections on professionalism workshops and lectures^40,42,43. The latter examples of resident-generated content are essential because they encourage self-directed learning and metacognition, or learning how one learns, thereby expanding the role of the portfolio to include teaching as well as assessment^42,44. Another important aspect of portfolio use is the mentorship of a faculty member who reviews the portfolio with the resident and helps the resident to set specific goals for future growth⁴². The portfolio can be used to track the development of the trainees as they become more self-aware of their attitudes and behaviors. Online portfolios can resolve the logistical issues associated with the collection, maintenance, and evaluation of portfolio content by residents and faculty^40,42.

Additionally, residents can be assessed with use of Objective Structured Clinical Examinations (OSCEs) and Unannounced Standardized Patients (USPs). The OSCE gives the resident an opportunity to practice a skill, such as delivering bad news, and receive feedback from a highly trained standardized patient⁴⁵. The USP typically visits the clinic under the guise of a real patient and is evaluated by the resident. The USP provides feedback to the resident through validated checklists and also provides information to the residency program that helps it in structuring its professionalism curriculum⁴⁶. Patient satisfaction surveys are also used to assess resident communication and professionalism.

Critical incident reporting is an additional strategy that can be used to evaluate professionalism in the workplace. Critical incidents are seminal events of unprofessional behavior. After reviewing the incident, a remediation plan is generated to address the behavior. The subsequent critical incident report documents and analyzes the event and uses standard terminology that can be incorporated into a structured framework for discussion (Table III). The reports can be utilized as both a mechanism to evaluate professional behavior and a means to teach the principles of professionalism. The reports maximize the residents’ investment in identifying important issues and developing correct behavior⁴⁷.

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TABLE III Critical Incident Report of Unprofessional Resident Behavior

Jeopardizing Patient Care
A male postgraduate year (PGY)-2 orthopaedic resident was on weekend call caring for patients on the inpatient service. The resident was required to remain in-house. Early in the evening, the resident left the hospital to visit a close relative who had been admitted to a nearby hospital with an acute myocardial infarction. The other hospital was about three miles away, and the resident estimated that his time away from the service would be less than one hour. The resident did not contact anyone to explain the situation, ask permission to leave, or try to obtain coverage. Approximately thirty minutes after leaving, the resident was called by nursing staff because a patient recovering from a total knee arthroplasty was complaining of shortness of breath. The resident indicated he would “be right there.” The patient rapidly decompensated over the next ten minutes and a code was called. The resident was paged using the emergency beeper that indicates the code and provides the location. The medical staff responded to the code and intubated the patient, who was found in cardiac arrest. The resident arrived twenty minutes later as the patient was being transferred to the angiography laboratory. The resident's absence was reported to the Residency Program Director that evening by the medical staff. An investigation took place over the next twelve hours, and the decision was made to summarily suspend the resident for conduct injurious to patients. The patient was found to have had a myocardial infarction in association with a pulmonary embolus. The patient was treated medically and discharged three weeks later after a difficult hospital course. Discussions were held among the Residency Program Director, the Department Chair, and the Associate Dean for Graduate Medical Education. The resident's performance up to that time had been satisfactory. However, this incident represented a very substantial lack of professionalism and deviation from appropriate patient care. The behavior of the resident seriously compromised the patient's recovery. Therefore, the decision was made to remove the resident from the training program for the remainder of the year (approximately seven months). He would be allowed to return to the program in July as a PGY-2 resident to repeat the year, but only if he fulfilled certain requirements that included participation in a structured professionalism program and completion of a paper on professionalism in medical practice. Moreover, he was placed in a research laboratory for the remainder of the year, with assigned responsibilities that included the completion of two projects. Finally, he was strongly encouraged to seek professional counseling, which he did. (The department could not require such counseling.) The resident successfully completed all of the requirements and reentered the program as a PGY-2 resident on a one-year probation with the understanding that a similar episode would result in termination from the program. He successfully completed the probationary period and the remainder of his residency in a satisfactory manner without any further issues.

Jeopardizing Patient Care

A male postgraduate year (PGY)-2 orthopaedic resident was on weekend call caring for patients on the inpatient service. The resident was required to remain in-house. Early in the evening, the resident left the hospital to visit a close relative who had been admitted to a nearby hospital with an acute myocardial infarction. The other hospital was about three miles away, and the resident estimated that his time away from the service would be less than one hour. The resident did not contact anyone to explain the situation, ask permission to leave, or try to obtain coverage. Approximately thirty minutes after leaving, the resident was called by nursing staff because a patient recovering from a total knee arthroplasty was complaining of shortness of breath. The resident indicated he would “be right there.” The patient rapidly decompensated over the next ten minutes and a code was called. The resident was paged using the emergency beeper that indicates the code and provides the location. The medical staff responded to the code and intubated the patient, who was found in cardiac arrest. The resident arrived twenty minutes later as the patient was being transferred to the angiography laboratory. The resident's absence was reported to the Residency Program Director that evening by the medical staff. An investigation took place over the next twelve hours, and the decision was made to summarily suspend the resident for conduct injurious to patients. The patient was found to have had a myocardial infarction in association with a pulmonary embolus. The patient was treated medically and discharged three weeks later after a difficult hospital course. Discussions were held among the Residency Program Director, the Department Chair, and the Associate Dean for Graduate Medical Education. The resident's performance up to that time had been satisfactory. However, this incident represented a very substantial lack of professionalism and deviation from appropriate patient care. The behavior of the resident seriously compromised the patient's recovery. Therefore, the decision was made to remove the resident from the training program for the remainder of the year (approximately seven months). He would be allowed to return to the program in July as a PGY-2 resident to repeat the year, but only if he fulfilled certain requirements that included participation in a structured professionalism program and completion of a paper on professionalism in medical practice. Moreover, he was placed in a research laboratory for the remainder of the year, with assigned responsibilities that included the completion of two projects. Finally, he was strongly encouraged to seek professional counseling, which he did. (The department could not require such counseling.) The resident successfully completed all of the requirements and reentered the program as a PGY-2 resident on a one-year probation with the understanding that a similar episode would result in termination from the program. He successfully completed the probationary period and the remainder of his residency in a satisfactory manner without any further issues.

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TABLE III Critical Incident Report of Unprofessional Resident Behavior

Jeopardizing Patient Care
A male postgraduate year (PGY)-2 orthopaedic resident was on weekend call caring for patients on the inpatient service. The resident was required to remain in-house. Early in the evening, the resident left the hospital to visit a close relative who had been admitted to a nearby hospital with an acute myocardial infarction. The other hospital was about three miles away, and the resident estimated that his time away from the service would be less than one hour. The resident did not contact anyone to explain the situation, ask permission to leave, or try to obtain coverage. Approximately thirty minutes after leaving, the resident was called by nursing staff because a patient recovering from a total knee arthroplasty was complaining of shortness of breath. The resident indicated he would “be right there.” The patient rapidly decompensated over the next ten minutes and a code was called. The resident was paged using the emergency beeper that indicates the code and provides the location. The medical staff responded to the code and intubated the patient, who was found in cardiac arrest. The resident arrived twenty minutes later as the patient was being transferred to the angiography laboratory. The resident's absence was reported to the Residency Program Director that evening by the medical staff. An investigation took place over the next twelve hours, and the decision was made to summarily suspend the resident for conduct injurious to patients. The patient was found to have had a myocardial infarction in association with a pulmonary embolus. The patient was treated medically and discharged three weeks later after a difficult hospital course. Discussions were held among the Residency Program Director, the Department Chair, and the Associate Dean for Graduate Medical Education. The resident's performance up to that time had been satisfactory. However, this incident represented a very substantial lack of professionalism and deviation from appropriate patient care. The behavior of the resident seriously compromised the patient's recovery. Therefore, the decision was made to remove the resident from the training program for the remainder of the year (approximately seven months). He would be allowed to return to the program in July as a PGY-2 resident to repeat the year, but only if he fulfilled certain requirements that included participation in a structured professionalism program and completion of a paper on professionalism in medical practice. Moreover, he was placed in a research laboratory for the remainder of the year, with assigned responsibilities that included the completion of two projects. Finally, he was strongly encouraged to seek professional counseling, which he did. (The department could not require such counseling.) The resident successfully completed all of the requirements and reentered the program as a PGY-2 resident on a one-year probation with the understanding that a similar episode would result in termination from the program. He successfully completed the probationary period and the remainder of his residency in a satisfactory manner without any further issues.

Jeopardizing Patient Care

Successful strategies for assessing the effectiveness of instruction in medical ethics have also been reported in orthopaedics. Wenger et al. successfully used a twenty-two-item survey involving thirteen brief clinical scenarios and nine short-answer questions to measure knowledge gains after a one-year curriculum of monthly case presentations and group discussions²⁵. Additionally, Baldwin et al. utilized the Defining Issues Test, which is a well-established measure of moral decision-making^5,18,48.

Conclusions

Professionalism encompasses the behaviors, attitudes, and conduct of physicians in their interactions with patients, faculty, colleagues, and staff. Today, many aspects of surgical practice threaten the foundation of professional behavior. To maintain the sanctity of the patient-physician relationship and promote high-quality patient care, professionalism must be at the core of residency education. Professionalism can be taught, and residency programs must employ both formal and informal approaches. The formal curriculum ensures that the concepts of professionalism are defined and presented to residents, whereas the informal curriculum helps trainees to translate those concepts into practice. Episodes of unprofessional behavior should be comprehensively reviewed, and a corrective plan of action should be developed. Residents’ understanding of professionalism and their ability to act professionally should be routinely assessed. Doing so will improve the quality of patient care, both during and after residency training.

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Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

internship and residency ; professionalism

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Joseph D. Zuckerman, Justin P. Holder, John J. Mercuri, Donna P. Phillips, Kenneth A. Egol; Teaching Professionalism in Orthopaedic Surgery Residency Programs. The Journal of Bone & Joint Surgery. 2012 Apr;94(8):e51 1-7.

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