This article proposes a partnership of state medical boards with medical schools to supplement professionalism and ethics education for medical students, residents, physicians and faculty members of medical institutions. The importance of professionalism has been recognized by several studies, but a specific method of teaching and developing professionalism has yet to emerge. Studies suggest that there is an association between a lack of professionalism in medical school and future disciplinary actions by medical boards. However, there has been little collaboration between these institutions in addressing unprofessional behaviors. One collaborative concept that holds promise, however, is the idea of inviting medical students to attend physician disciplinary hearings. Students and physicians alike report that watching a hearing can significantly impact attitudes about professionalism as a part of medical practice. While formal research is scarce, the positive response of individual students who experience disciplinary hearings firsthand suggests that further pilot studies may be useful. Presented in this paper are the perspectives of three individuals — a medical student, a faculty member and a medical board chair — who discuss the impact and potential of attending disciplinary hearings in developing professionalism and ethics. Also included is a review of the current literature.
Professionalism has been recognized as a necessity for physicians. The Accreditation Council for Graduate Medical Education (ACGME) lists professionalism as one of its six areas where residents must obtain competency.1 The Association of American Medical Colleges also recognizes the significance of professionalism education, emphasizing the importance of collaborative practice across different professions.2 In addition, an emphasis on undergraduate medical education professionalism education has grown in the United States. It has been found that “although most medical schools in the United States now address this important topic in some manner, the strategies used to teach professionalism may not always be adequate.”3 Even with this attention on professionalism education, graduating medical students may find it difficult to apply theoretical knowledge to real case scenarios in the medical setting.
In one case, 150 fourth-year medical students from Emory School of Medicine, working in the emergency department, were instructed to write narratives related to professionalism. Many students struggled with applying their didactic professionalism education to real-life scenarios. They had trouble dealing with issues such as “how to deal with patients who might be ‘drug seekers’ and when to prescribe narcotics.” “[A]bsence of compassion, physicians lying, and a lack of teamwork” were seen by the students.4 With poor clinical role models and without understanding of the consequences of improper behavior, it is difficult for medical students to apply an abstract principle such as professionalism to their daily work as physicians.
Discrepancies between abstract and concrete examples of professionalism were also seen in senior medical students at three universities.5
Studies performed by Dr. Papadakis, et al, suggest a strong association between a lack of professionalism seen in medical students and incidents with state board disciplinary hearings years later.6,7,8 However, little data exists on the effectiveness of collaborations between medical boards and medical schools aimed at cultivating professionalism in students.
Florida State University College of Medicine and the Florida State Board of Medicine joined forces to educate students on professionalism by inviting them to disciplinary hearings.
A medical student's account of her experience with a disciplinary hearing is presented here, along with the perspectives of her faculty mentor and a member of the medical board conducting the hearing. (Note: The names of the participants have been kept anonymous.)
A Medical Student's Perspective
“As the room starts to fill, I begin feeling a bit nervous. In front of me is a horseshoe arrangement of physicians, who are today acting as disciplinarians. Next to me is also a crowd of physicians, yet they are playing the role of the blamed. I soon learn that most of these physicians have made mistakes; Dr. X forgot to chart something properly, Dr. Y missed an abnormal lab value, and Dr. Z failed to refer a patient to a specialist. Most physicians are clearly remorseful and some have already taken action within their practice to prevent such mistakes in the future. I can relate to the human factor of being a physician; humans make mistakes. However, physicians are held to a higher standard. Such simple mistakes are easy to make but also easy to prevent. Most do not result in harm to patients, yet tell that to the one patient who has the poor outcome.
“One case in particular leaves me uneasy. As the physician and his lawyer sit before the ‘judges,’ there is a different tone in the air. I don't see remorse on his face; I don't hear regret in his voice, yet this is by far the most serious case of the day. This physician missed signs and symptoms of prescription drug abuse that led to the death of two young patients. I feel sick. Why was he prescribing such large quantities of pills? Didn't he feel the need to refer them to a specialist with such a complicated psychiatric case? How did he fail to evaluate his practice after the death of the first patient? The board members must be having the same internal monologue because they begin asking similar questions. These questions are never answered.
“The mother of one of the deceased takes the stand. Her son was the second young man to die. She is emotional but surprisingly levelheaded as she confronts the physician, who wrote her son prescriptions for hundreds of pills a month. The doctor fails to remember the name of the deceased. I am shocked. He sees no wrongdoing on his part. I start trying to rationalize, but my shock is replaced by anger, disgust, and disappointment. The members of the board suspend the physician's medical license until further investigation is complete.
“As a medical student, professionalism and ethics are part of the curriculum to graduate. We spend hours in lecture and in small groups discussing issues such as patient autonomy, disclosure of medical errors, and the patient-physician relationship. However, nothing has taught me the consequences of lapses in professionalism like spending a few hours watching a Board of Medicine disciplinary hearing. This is real life, not theory. I think it is essential for students to learn how the system works for disciplining physicians. There is no better way to learn than sitting in on a hearing. All of those lessons in professionalism are brought into context. I have a new-found respect for the active efforts necessary to prevent mistakes, as it is each individual physician's responsibility to act professionally and ethically.”
A Faculty Mentor's Perspective
“As a clerkship director in family medicine, it is my job to guide the education of third- and fourth-year medical students. I am responsible for teaching them how to take a history, perform a physical exam, and diagnose a clinical problem. Throughout this process there is a fundamental concept of professionalism. I believe that the most important thing a professor of medicine can do is set an example of professionalism and hold your students accountable to high standards.
“At our university's medical school, professionalism is woven throughout the curriculum. I recently supervised a senior doing an elective rotation on Professionalism and Ethics. As part of her rotation, she attended and observed a disciplinary meeting of our state board. At this meeting 11 physicians were disciplined for reasons ranging from poor documentation to gross negligence that resulted in a patient's death. The act of seeing the consequences of poor professionalism in practice, and the subsequent punishment, had a powerful impact on this student.”
A Board Member's Perspective
“My experience as a member of a state medical board and as a faculty member at a medical school has reaffirmed my belief in the need for a proactive stand to address issues of professionalism, ethics, and compassion in medicine. I have seen several students and medical professionals positively impacted after witnessing even one state board meeting; licensed physicians can also receive continuing medical education credit through attending a board meeting. Linking classroom lectures to real-life scenarios and demonstrating the gravity of carelessness and unprofessional behavior are a few positive outcomes from attending a meeting.
“There is a paucity of literature to substantiate the effectiveness of teaching professionalism to medical students utilizing partnerships with state medical boards. This needs to change. I have witnessed many students altering their approach towards professionalism and compassion after seeing the mistakes of others. I have also spoken to many colleagues who attended disciplinary hearings for continuing medical education credits. From an intellectual standpoint, they found the cases to be fascinating. They were also surprised that medical board members were not as cruel as they had envisioned them. Linking medical education with disciplinary hearings could have a profound effect on the future of professionalism in medicine as a whole.”
These three perspectives touch on many of the intricacies of professionalism in regards to medical school education curriculum. The student witnesses various lapses in professional judgment that elicit a logical as well as emotional response. One of the great difficulties in educating students on professionalism is trying to establish a definition. These topics are abstract and intangible, making them hard to communicate.
Vanderbilt University School of Medicine (VUSM) has found success in teaching professionalism by “identifying, measuring, and addressing unprofessional behaviors.”9 The Florida Board of Medicine's disciplinary hearing outlines evident examples of unprofessional behaviors and their penalties. The faculty mentor specifically notes the effectiveness of seeing “consequences of poor professionalism in practice.” The principles of professionalism that students learn are often discovered through the actions and examples displayed by other professionals in the hospital rather than through lecture in the classroom.10
One of the major issues with the medical education community's presentation of professionalism concepts in the classroom setting is that this approach cannot fully address and communicate the contextual nature of professionalism.4 Exposure to actual cases of unprofessional behaviors allows students to understand their significance; one infraction could ultimately lead to revocation of one's medical license. While classical didactic education is important, it is also important that it be coupled with experiential learning, which allows the application of that didactic knowledge.10
It's important to note that the student quoted in this paper makes the assertion that “[medical students] spend hours in lecture and in small groups discussing issues such as patient autonomy, disclosure of medical errors, and the patient-physician relationship. However, nothing has taught me the consequences of lapses in professionalism like spending a few hours watching a Board of Medicine disciplinary hearing. This is real life, not theory.” This testimony suggests a great deal of potential in an area that demands more quality research.
How do we move the teaching of professionalism forward using a collaborative approach, given what we know today?
Clearly, the first step is raising awareness of the potential for collaboration between state medical and osteopathic boards and the educational community in addressing this question. Within the Federation of State Medical Boards, few states have created documented initiatives to contribute to medical education — among them, Ohio, Arizona, Florida and Michigan. A broader effort is needed.
There is evidence that visits to state medical boards are being considered as a component of a professionalism curriculum by some medical colleges. Others may be in various stages of developing these programs, but there is a lack of published material to document these efforts.
The active programs in Ohio, Arizona, Florida and Michigan provide ideas that could be emulated by others:
In 2007 Dean John Brose, D.O., of the Ohio University College of Osteopathic Medicine joined forces with Richard Whitehouse, executive director of the State Medical Board of Ohio, to develop Partners in Professionalism, which was “designed to educate students on the responsibilities that come with a medical degree.” The program, which is intended to promote “professionalism and emphasize the ethical responsibilities of medical licensure to medical students” by bringing them to disciplinary hearings, is required for all first-year medical students.
The program educates medical students on how to avoid problematic behavior or practices through increasing awareness of state medical board functions and the regulations put on medical practice. Students are presented with information on the state medical board and the cases that will be seen before a meeting and are provided time after the actual meeting to ask questions of board members. The response from students has been overwhelmingly positive, according to program coordinators, with students consistently calling the experience “educational and eye-opening.”11,12
At the School of Osteopathic Medicine in Arizona (SOMA), the importance of professionalism in medicine is taught through the Arizona Board of Medicine. For more than a decade, medical students from several schools have been attending these board meetings. Now SOMA medical students are required to attend a state medical board meeting in order to reinforce lessons of professionalism and to witness regulatory issues that physicians can face.13
In 2010 the Florida Board of Medicine, under the leadership of Onelia G. Lage, M.D., a pediatrician from the University of Miami Miller School of Medicine (and co-author of this article), initiated the “Chair's Recognition Award” for medical students. One fourth-year medical student from each of the five Florida medical schools, as selected by the schools' deans, was awarded this honor for their high standards of academic excellence, professionalism, character, and humanism. Students were required to attend the Board of Medicine disciplinary meeting, where they received their award and a copy of the book “Better: A Surgeon's Notes on Performance” by Atul Gawande. In addition, Florida Board of Medicine members presented lectures not only to licensed physicians across the state but also to medical students and residents in training.14 Inclusion of effective communication-skills training has also been utilized with students and house staff. Inviting deans to host Board of Medicine meetings on their campuses has also been explored; this would make it more feasible to have faculty and students participate.
Presence at disciplinary hearings isn't the only way to raise awareness of professionalism among medical students through collaboration between schools and state boards. More targeted instruction on medical regulation can also help. The Michigan Bureau of Health Professions recently launched a web-based training module titled “Licensing, Professionalism and the Regulatory Process” for medical students, physicians and other health care professionals. The program has received positive feedback from medical students, who had felt their exposure to professionalism, licensing and regulation information had been lacking.15
It's worth noting that, while most of the programs cited in this article make it possible for students to be physically present during disciplinary hearings, distance may be an issue for some medical programs. This issue may be circumvented with teleconferencing, which can be pragmatically used in the medical classroom. A drawback of this approach is that it may bring medical legal concerns in certain states.
Medical education is very consciously moving into the realm of ethics and professionalism; collaboration with state medical boards offers a new frontier for instilling medical professionalism in students. As healthcare professionals face increasingly complex ethical issues in practice, it becomes even more important for two of the institutions that have the most interaction with individuals on these terms — state medical boards and medical schools — to collaborate on methods for producing more ethical, conscientious physicians. We encourage state medical boards to reach out to medical schools to develop these partnerships on their own. Attendance by medical students at state medical board disciplinary hearings is just one way to achieve this goal. As more of these programs grow, it is clear that more research needs to be implemented to chart their effect on students.