Context.—

Changes occurring in medicine have raised issues about medical professionalism. Professionalism is included in the Core Competencies and Milestones for all pathology residents. Previous studies have looked at resident professionalism attitudes and behaviors in primary care but none have looked specifically at pathology.

Objective.—

To examine behavior and attitudes toward professionalism within pathology and to determine how professionalism is taught in residency programs.

Design.—

Surveys were sent to all College of American Pathologists junior members and all pathology residency program directors, and responses were compared.

Results.—

Although no single behavior received the same professionalism rating among residents and program directors, both groups identified the same behaviors as being the most unprofessional: posting identifiable patient information or case images to social media, making a disparaging comment about a physician colleague or member of the support staff on social media or in a public hospital space, and missing work without reporting the time off. Faculty were observed displaying most of these behaviors as often or more often than residents by both groups. The most common means to teach professionalism in pathology residencies is providing feedback as situations arise and teaching by example. Age differences were found within each group and between groups for observed behaviors and attitudes.

Conclusions.—

As teaching by example was identified as a common educational method, faculty must be aware of the role their behavior and attitudes have in shaping resident behavior and attitudes. These results suggest a need for additional resources to teach professionalism during pathology residency.

Physician professionalism has received increased attention in recent decades as changes in health care delivery and payment, technologic advances, an explosion in information, and a more complex practice environment have all changed the practice of medicine and are changing the relationships between physicians and patients.1,2  Residency program requirements task program directors (PDs) and faculty to teach and evaluate professionalism as one of the Core Competencies developed by the Accreditation Council for Graduate Medical Education (ACGME) in association with the American Board of Medical Specialties.3  The Core Competencies have been incorporated into the Pathology Milestones by the Pathology Residency Review Committee of the ACGME4  and are used for Maintenance of Certification by the American Board of Pathology.5 

Several authors have examined professional behavior among residents and the teaching and assessment of professionalism in primary care residency programs.612  There is little literature regarding the teaching of professionalism to pathology residents13,14  and none regarding the attitudes or behaviors of pathology residents regarding professionalism. We ascertained resident attitudes toward selected potentially unprofessional behaviors and compared these with PD attitudes. We also explored how often residents and faculty exhibit these behaviors and assessed how professionalism is taught in pathology residency programs.

Pathology residents and residency PDs in the United States were invited to participate in anonymous online surveys administered with Survey Monkey (Palo Alto, California). An email invitation was sent to all residents who were junior members of the College of American Pathologists (CAP). An initial screening question asked respondents to indicate their residency training program year; those who selected “I have completed residency training” were screened out of the survey. Program directors were invited to participate in a separate survey through the PRODS listserv of the Program Directors Section (PRODS) of the Association of Pathology Chairs. An initial screening question asked respondents to indicate if they were the designated pathology residency PD or associate PD for their institution. Respondents selecting “no” were screened out of the survey.

Both the resident and PD surveys included the same 21 behavioral statements related to patient care, interpersonal interaction, and other workplace behaviors. Many of these statements were adapted from prior research.6  Similar items (eg, “raised voice at a member of the support staff” and “raised voice at a physician colleague”) were placed on different pages of the survey to decrease the likelihood of respondents referring to their prior responses when rating each statement.

Resident Survey

Survey questions were organized into 4 main sections as described below.

Participation/Observation Ratings

Residents rated each behavioral statement on 2 dimensions: Participation (How often have you participated in this behavior?) and Faculty Observation (How often have you observed this behavior among faculty?). Response options for both ranged from “very often (5)” to “never (1).” For the observation ratings respondents also had the option to select “uncertain.”

Professionalism Ratings

Residents rated the professionalism of each of the 21 behaviors that were presented in the same order as the participation/observation ratings. Response options included the following: fully professional (5), somewhat professional (4), neutral (3), somewhat unprofessional (2), and fully unprofessional (1).

Residency Training Curriculum

Residents provided information about their residency training program's formal curriculum related to professionalism. The survey included questions related to documentation of professionalism expectations, professionalism topics covered and methods of teaching those topics, feedback received about professionalism, and willingness to report concerns about the professionalism of other trainees and faculty to PDs.

Demographic Questions

Residents answered demographic questions about their sex, age, and residency training program size.

Program Director Survey

Questions were organized into the same 4 sections.

Observation Ratings

Program directors rated each behavior on 2 dimensions: Faculty Observation (How often have you observed this behavior among faculty?) and Resident Observation (How often have you observed this behavior among residents?).

For both ratings, response options ranged from “very often (5)” to “never (1).” Respondents also had the option to select “uncertain.”

Professionalism Ratings

Program directors rated the professionalism of each of the 21 behaviors by using the same response scale as was used on the resident survey.

Residency Training Curriculum

Program directors provided information about the formal professionalism curriculum of their residency training. The survey included questions about documentation of professionalism expectations, professionalism topics covered and methods of teaching those topics, provision of feedback about professionalism by the chief resident, and experience initiating a formal remediation plan and/or dismissing a resident owing to professionalism issues.

Demographic Questions

Program directors answered demographic questions about their sex, age, residency training program size, and tenure as a PD.

Descriptive statistics were computed for all survey questions. Comparisons of survey responses based on respondents demographics (ie, sex and age), as well as comparisons between resident and PD responses, were analyzed by using 2-tailed t tests. The criterion for significance was set at 0.05 (SPSS version 23, IBM Corp, Armonk, New York). Because not every respondent answered every question, the number of respondents for each question does not always equal the total number of survey respondents. Percentages do not always add up to 100% owing to rounding or multiple response options.

Response rates for residents and PDs are shown in the Figure. For residents, the overall response rate was 15% (n = 308 of 2067) with a 10% (n = 208 of 2067) usable response rate. For PDs, the overall response rate was 50% (n = 71 of 142) with a 44% (n = 62 of 142) usable response rate. Demographic data for the resident and PD groups are shown in Tables 1 and 2, respectively.

Table 1. 

Resident Demographics

Resident Demographics
Resident Demographics
Table 2. 

Program Director Demographics

Program Director Demographics
Program Director Demographics

Response rates per respondent group. Abbreviations: CAP, College of American Pathologists; PDs, program directors; PRODS, Program Directors Section of the Association of Pathology Chairs.

Response rates per respondent group. Abbreviations: CAP, College of American Pathologists; PDs, program directors; PRODS, Program Directors Section of the Association of Pathology Chairs.

Close modal

Program Directors and Residents Agree on Which Behaviors Are Most Unprofessional

Responses to the professionalism of behaviors ratings portion of the resident and PD surveys are displayed in Supplemental Table 1 (see supplemental digital content, containing 3 tables at www.archivesofpathology.org in the October 2017 table of contents).

As shown in Table 3, residents and PDs identified the same behaviors as being the most unprofessional (somewhat or fully unprofessional): posting identifiable patient information or case images to social media, making a disparaging comment about a physician colleague or member of the support staff on social media or in a public hospital space, and missing work without reporting the time off. Residents identified 1 additional behavior as unprofessional: not answering pages promptly. Mean comparisons were conducted to determine if resident and PD ratings of professionalism differed significantly. Fifteen of the 21 practice areas (71%) received comparable ratings from residents and PDs. As shown in Table 4, PDs rated 6 behaviors significantly less professional on average than did residents. Residents rated just 1 behavior (raised voice at a physician colleague) significantly less professional than did PDs (significance information is presented in Table 4).

Table 3. 

Behaviors Most Consistently Rated Unprofessionala

Behaviors Most Consistently Rated Unprofessionala
Behaviors Most Consistently Rated Unprofessionala
Table 4. 

Behaviors With Significant Differences in Professionalism Ratings

Behaviors With Significant Differences in Professionalism Ratings
Behaviors With Significant Differences in Professionalism Ratings

While there were no behaviors that either all residents or all PDs agreed were unprofessional, greater than 90% of residents and PDs agreed that the following 3 behaviors were fully unprofessional: made a disparaging comment about a physician colleague on social media (residents 91% [n = 172 of 190]; PDs 93% [n = 52 of 56]); posted patient information and/or case images with personally identifiable information to social media (residents 97% [n = 183 of 189]; PDs 96% [n = 54 of 56]); made a disparaging comment about a member of the support staff on social media (residents 92% [n = 174 of 189]; PDs 96% [n = 52 of 54]).

There were no significant differences in professionalism ratings observed between male and female residents or male and female PDs.

Residents' Perceptions of Their Participation Differ From Those of Program Directors, but Perceptions Align With Respect to Faculty Participation

Responses to the resident participation portion of the resident and PD surveys are displayed in Supplemental Table 1.

Residents and PDs agreed on 4 of the 5 most frequently reported behaviors among residents, namely, complaints about workload/regulations, use of mobile devices for work or non–work-related purposes during lecture or sign-out, and arriving late to lecture (Table 5). Program directors reported observing each of the behaviors among residents significantly more often than residents reported having participated in the behaviors. There was 100% agreement between residents and PDs with regard to the most frequent behaviors in which they observed faculty participating (Table 6). These largely overlap with the most frequently observed behaviors among residents.

Table 5. 

Top 5 Most Frequently Reported Behaviors Among Residentsa

Top 5 Most Frequently Reported Behaviors Among Residentsa
Top 5 Most Frequently Reported Behaviors Among Residentsa
Table 6. 

Top 5 Most Frequently Reported Behaviors Among Facultya

Top 5 Most Frequently Reported Behaviors Among Facultya
Top 5 Most Frequently Reported Behaviors Among Facultya

Residents Participate in Behaviors That They Rate as Unprofessional

Additional analyses were conducted to determine if residents who indicated that they sometimes to very often participate in the specific behaviors surveyed also rated those same behaviors as unprofessional. Complete results from this analysis are provided in Supplemental Table 2. Examination of the 5 highest frequency resident behaviors (Table 5) suggested most residents who sometimes to very often participated in the following 3 behaviors also believed these behaviors to be unprofessional: arrived late to a required lecture or rounds when no truly urgent clinical issue needed attention (75% [n = 45 of 60 who indicated they participated in this behavior at least sometimes] also rated it unprofessional); discussed patient information in a public hospital space (eg, elevator, cafeteria, parking lot) (73% [n = 22 of 30 who indicated they participated in this behavior at least sometimes] also rated it unprofessional); used a mobile device for non–work related purposes during a lecture or sign-out (59% [n = 27 of 46 who indicated they participated in this behavior at least sometimes] also rated it unprofessional).

A notably smaller proportion of residents who sometimes to very often participated in the other 2 most frequent behaviors believed them to be unprofessional: used a mobile device for work-related purposes during a lecture or sign-out (27% [n = 23 of 85 who indicated they participated in this behavior at least sometimes] also rated it unprofessional); complained to a colleague about workload or hospital policies/procedures (16% [n = 18 of 113 who indicated they participated in this behavior at least sometimes] also rated it unprofessional).

Generational Differences Exist Among Residents With Respect to Participation and Professionalism Ratings

Younger residents (<35 years) participated in 10 of the 21 behaviors significantly more often than did older residents (significance information is presented in Table 7). Despite the differences observed, it should be noted that the mean ratings for both age groups still reflect relatively low levels of participation on average. Older residents (≥35 years) rated 4 of the 21 behaviors significantly less professional than did younger residents (significance information is presented in Table 8). However, the mean ratings for both groups indicate that the behaviors are generally perceived as unprofessional. Program directors aged 50 years or older rated 3 of the 21 behaviors significantly less professional than did younger PDs (significance information is presented in Table 9). For all behaviors, no significant differences in participation ratings were observed between male and female residents.

Table 7. 

Differences in Resident Participation Ratings Based on Resident Age

Differences in Resident Participation Ratings Based on Resident Age
Differences in Resident Participation Ratings Based on Resident Age
Table 8. 

Differences in Professionalism Ratings Based on Resident Age

Differences in Professionalism Ratings Based on Resident Age
Differences in Professionalism Ratings Based on Resident Age
Table 9. 

Differences in Professionalism Ratings Based on Program Director Age

Differences in Professionalism Ratings Based on Program Director Age
Differences in Professionalism Ratings Based on Program Director Age

Professionalism Expectations Are Disseminated Through Institutional-Wide Training Sessions Supplemented by Handbooks

Detailed results for the questions regarding professionalism curriculum questions can be found in Supplemental Table 3. Most PDs (84%, n = 47 of 56) indicated relying on institutional/hospital-wide sessions. Most PDs and residents (>90% each; n = 54 of 56 and n = 175 of 186, respectively) indicated that general employment policies, rights and responsibilities related to electronic medical records access, and patient privacy/Health Insurance Portability and Accountability Act (HIPAA) are discussed with residents. A smaller percentage, 79% (n = 44 of 56) of PDs and 73% (n = 135 of 186) of residents, indicated discussing use of social media. While still a majority, notably fewer programs discuss “soft skill” professionalism topics. Eighty-two percent (n = 46 of 56) of PDs and 74% (n = 137 of 186) of residents indicated that interpersonal behavior and expectations related to interactions with others are discussed.

Most residency training programs provided residents with a handbook that outlined expectations related to professionalism: 71% of PDs (n = 40 of 56) and 66% (n = 124 of 187) of residents indicated that such a handbook is provided. Seventy percent (n = 131 of 186) of residents had read the Pathology Milestones related to professionalism.

Providing Feedback Is the Most Common Method to Teach and Address Professionalism Behaviors, With Chief Residents Having a Role

The most common methods of teaching professionalism are to “provide feedback as situations arise” (selected by 98% [n = 55 of 56] of PDs and 79% [n = 145 of 184] of residents) and “teach by example” (selected by 89% [n = 50 of 56] of PDs and 75% [n = 138 of 184] of residents). Notably fewer PDs (59%, n = 33 of 56) and residents (47%, n = 87 of 184) report having given or received mandatory lectures or talks on professionalism.

Eighty-eight percent (n = 164 of 187) of residents indicated they are provided feedback about their professionalism: 52% (n = 86 of 164) had been provided positive feedback only and another 41% (n = 67 of 164) had been provided both positive and negative feedback. Seventy-nine percent (n = 45 of 57) of PDs indicated their chief residents either provide all residents feedback on their professionalism (12%; n = 7 of 57) or provide corrective feedback as situations arise (67%; n = 38 of 57). Another 14% (n = 8 of 57) of PDs were uncertain if their chief residents provide feedback on professionalism.

Concerns About Unprofessional Behavior Among Other Residents and Faculty Are Likely Underreported

Less than half (43%; n = 79 of 185) of residents would definitely report concerns about the professionalism of other trainees to their PD. Another 50% (n = 92 of 185) responded “maybe.” Forty-three respondents who selected “maybe” provided an explanatory comment. The most common theme (33 comments or 77%) was that this would depend on the situation/severity of the issue. The second most common response (14 comments or 33%) cited the effect on patient safety or patient care as a determining factor in reporting unprofessional behavior. The third most common response (6 comments or 14%) indicated a preference to first speak directly with the trainee about the situation.

Similarly, only 37% (n = 68 of 184) of residents would definitely report concerns about the professionalism of faculty to their PD. Another 49% (n = 90 of 184) responded “maybe.” Thirty-six respondents who selected “maybe” provided an explanatory comment. Again the most common theme (20 comments or 56%) was that this would depend on the situation/severity of the issue. Another 5 comments (14%) described concerns related to political hierarchy, anonymity, and retaliation. Twelve respondents who selected “no” commented, and 9 of these comments (75%) described concerns related to fear of retaliation and/or a belief that this feedback would not be welcomed by the program.

Formal Remediation Plans for Professionalism Issues Are Frequent

Half of PDs (50%; n = 29 of 58) had initiated a formal remediation plan for a resident owing to professionalism issues. All of these PDs provided an explanatory comment regarding the nature of the professionalism issue that resulted in formal remediation. Twelve comments (41%) described inappropriate communication and interactions with others, 7 comments (24%) described a failure to meet the responsibilities of the job, and 6 comments (21%) indicated the resident consistently arrived late to work. Only 5 of 57 PDs (9%) had dismissed a resident because of professionalism issues. Owing to the small number of respondents, no common themes could be identified.

This study examined pathology resident and PD attitudes toward specific potentially unprofessional behaviors and activities as well as how often residents and faculty exhibit those behaviors. In addition, both groups were queried about how professionalism is taught in their residency programs. Resident response frequencies of admitting to participating in unprofessional behaviors suggested a reasonable degree of candidness. The only behavior in which no residents indicated participating was “posted patient information and/or case images with personally identifiable information to social media.” Residents and PDs agreed on 4 of the 5 most frequently reported resident behaviors, and 5 of the 5 most frequently reported faculty behaviors.

No significant differences in behavior participation ratings or professionalism ratings were observed between male and female residents or PDs. This differs from the finding in the study by Nagler et al.6  In their study of entering postgraduate 1 (PGY-1) residents at 2 institutions, men were more likely to rate all behaviors presented as professional and were more likely to participate in the behaviors than women. Our survey used similar behaviors to the ones used in their study but included predominantly residents beyond the first year of training and practicing pathologists. The discrepancy in findings might be an example of inculcation of values as seen with other professions and institutions such as the military and religious or educational institutions.15 

Age differences were seen in the participation portion of the resident cohort in almost half of the behaviors, with younger residents participating more frequently in the behaviors cited. Views on professionalism showed a smaller number of differences by age for both the residents and PDs, as compared to participation in said behaviors. Comparing resident and PD professionalism ratings, there were significant differences in the rating of one-third of the behaviors, with PDs tending to have more conservative opinions as to what constituted professional behaviors. However, both groups agreed on the top 6 behaviors that were rated as the most unprofessional. These findings suggest a slight generational difference, albeit one different from that found in the study by Borrero et al.7  In that study, first- and second-year internal medicine residents and faculty at 1 institution were given vignettes with specific unprofessional behaviors and were asked to rate the severity of the infraction in each vignette. Their results showed only minimal differences in responses between the 2 groups and only 2 of 16 vignette responses showed a significant difference between residents and faculty, suggesting no generational difference existed. As our study queried residents and PDs from multiple institutions in different parts of the country, it may have been able to pick up differences that a single institutional survey could not.

This study helps delineate the boundaries of professionalism in pathology in that most study participants perceived all the behaviors as generally unprofessional (either somewhat or fully unprofessional). While there were no behaviors that either all residents or all PDs agreed were unprofessional, greater than 90% of residents and PDs agreed that 10 behaviors were unprofessional, 3 of these pertaining to social media. Although they were not frequently reported, both residents and faculty were observed participating in these behaviors “sometimes” and “rarely” by PDs. Given that social media is less frequently discussed during professionalism training sessions, these data indicate a need for more discussion. In addition, the range of opinions regarding which behaviors are fully unprofessional, similar to the study by Borrero et al,7  has implications when discussing how to define professional behavior, teach professionalism, and remediate unprofessional behavior.

It is interesting to note that residents observed participation in unprofessional behaviors significantly more often in faculty than themselves in 17 of 21 behaviors. While an inherent response bias might be partly responsible for these results, the PD survey corroborates these results: on average, PDs observed faculty participating in 19 of the 21 behaviors the same as or more often than residents. One of these behaviors is “discussed patient information in a public hospital space.” Faculty members were observed exhibiting this behavior more often than or comparable to the resident group even though this behavior is explicitly prohibited in HIPAA training that both residents and faculty receive. This indicates a need to reinforce HIPAA requirements for both residents and faculty, particularly with respect to conversation with colleagues in public areas. Program directors also observed faculty engaging in 3 potentially unprofessional behaviors significantly more often than residents. Given these results and the finding that the second most common method for teaching professionalism is teaching by example, faculty actions may influence resident professional behavior and attitudes more than institution-wide sessions upon which many programs (84% in our PD survey) rely to teach professionalism.

As faculty members are role models for residents, residents learn about professionalism norms and values by watching the actions or inactions of the faculty (teaching by example). Teaching by example, or role modeling, is situated (situational) learning where learning occurs through the teacher's actions and responses rather than by direct instruction. Cruess and Cruess16  note that role modeling is “the most potent means of transmitting those intangibles that have been called the art of medicine.” They also state that role models are important for developing the collegiality necessary to create common professional goals and ensure compliance with them. Similarly, Zaino and Abendroth,17  in examining how residents learn during surgical pathology sign-outs, discuss how residents learn much about professionalism by watching how attending staff communicate and behave with other members of the health care team, handle errors, and deal with uncertainty. They note that if attending staff model a behavior, residents are more likely to adopt it.

This informal, or hidden, curriculum was first described in the medical literature in 199418 and is discussed in regard to residency training by Gaiser8  who states that the “hidden curriculum involves the knowledge taught through actions and words in the clinical situation.” He goes on to say that by observing the faculty, residents learn about professionalism from actions and the consequences of those actions. Gaiser8  notes that a role model can have a bigger impact on behavior than lectures about professionalism and that negative role models have more impact than positive role models. This hidden curriculum, then, must be kept in mind when developing any professionalism curriculum.

Considerations for creating a professionalism curriculum must include the presence of the hidden curriculum and the varying degrees of professionalism that residents and PDs perceive to be associated with certain behaviors. Pathology faculty must realize that they are all role models, positive and negative, for residents. Thus, faculty development to raise awareness of this hidden curriculum is necessary to bring this part of the professional curriculum to the forefront. Residents also need to be informed that this informal curriculum is part of their learning experience. While pathology-specific lectures and institution-wide sessions can impart basic guidelines of professional behavior, the actions of faculty and staff, as well as their own remediation by PDs or administration, are critically important in inculcating professional standards.

Since there are varying opinions on the degree to which certain behaviors are professional, there must be active discussion of behaviors within a “gray zone” of professionalism. This could include discussion of case-based scenarios in an effort to come to a more uniform consensus of what activities are fully unprofessional and how generational differences or circumstances can influence these perceptions.8  Both faculty and residents need to participate in the curriculum to understand the different viewpoints, appreciate the rationale behind them, and approach a consensus. Surveying residents at the beginning and the end of their residency, or shortly after graduation, to measure the effect of this curriculum could be a useful outcome measure.

There are limitations to our survey. The survey was distributed to all residents who were junior members of the CAP so those who participated represent a self-selected cohort and hence this is not a population-based survey. The resident response rate was low so this could contribute to survey bias. Also, as both the resident and PD surveys were anonymous, we cannot determine the geographic distribution of the responses so it is possible, although unlikely, that the residents who responded could represent a limited number of residency programs.

In summary, this study is the first to examine professionalism behaviors and attitudes among pathology residents and PDs. There were no sex differences, but slight generational differences in attitudes were found. Although all of the described behaviors were felt to be unprofessional to some degree, there was lack of agreement on the degree of unprofessionalism for most of the behaviors among residents and PDs. Evidence of the “hidden curriculum” was found in pathology just as it has been found in other medical specialties and education. These findings suggest a need for a robust professionalism curriculum for both faculty and residents.

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Author notes

From the Directorate for Clinical Operations, The Joint Pathology Center, Silver Spring, Maryland (Dr Brissette); Learning, College of American Pathologists, Northfield, Illinois (Dr Johnson); the Department of Pathology, Columbia University Medical Center-New York Presbyterian Hospital, New York (Dr Raciti); the Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City (Dr McCloskey); the Department of Pathology, Stanford University School of Medicine, Stanford, California (Dr Gratzinger); the Department of Pathology and Anatomy, Eastern Virginia Medical School, Norfolk, (Dr Conran); the Department of Pathology, Penn State Hershey Medical Center and College of Medicine, Hershey, Pennsylvania (Dr Domen); the Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee (Dr Hoffman); the Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora (Dr Post); the Department of Pathology, ProPath Associates, Dallas, Texas (Dr Roberts); the Department of Pathology, Medical College of Georgia-Augusta University, Augusta (Dr Rojiani); and the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas (Dr Powell).

Supplemental digital content is available for this article at www.archivesofpathology.org in the October 2017 table of contents.

Competing Interests

The authors have no relevant financial interest in the products or companies described in this article.

For Dr Brissette: The views expressed are those of the author and do not reflect the official policy of the Department of the Army/Navy/Air Force, Department of Defense, or US Government.

Supplementary data