Dr. Jim Grogan, residency program director, noted that the residents’ ratings of the new surgeon, Dr. Young, were low compared to those of other faculty members. But he decided to wait until the next quarter’s evaluations to see if he needed to meet with Dr. Young. Many of the next quarter’s ratings of Dr. Young fell into the marginal category. Several residents wrote that Dr. Young created an operating room environment that was not conducive to learning or quality patient outcomes. A few residents personally talked with Dr. Grogan about Dr. Young’s sarcastic remarks about their clinical performance. Dr. Grogan knew he needed to act, but he was unsure about how he should proceed.
Dr. Grogan is not alone. Other program directors may wonder how they should respond to the unprofessional behavior of faculty members in their programs. Below I describe general principles and techniques that might spur residency program directors to act and help them achieve a just, satisfying outcome for all concerned.
Heed the residents’ reports. In the short run, the easiest thing to do is to ignore the residents’ reports. Yet, according to several studies, the sooner one addresses sub-standard behavior, the more likely it can be changed.1 Moreover, a faculty member’s professional lapses, especially if unchecked, can impede the development of residents’ own professionalism, erode the learning environment, and affect patient care.
Fulfill your duty; exercise your authority. The residency director has the responsibility to assure that program faculty meet professionalism standards. Indeed, the director has the authority to determine who does and who does not teach residents.2
Observe due process. In responding to the professional lapse of a faculty member, the program director must follow due process to assure fair, even treatment of all parties. Due process consists of notifying the faculty member of the reported concerns or lapses, clearly stating the professional standard(s) he or she allegedly did not meet, arranging an opportunity for the faculty member to respond to the reports, following departmental/university policies, and assuring him or her the right to appeal any decision.1
Use a graduated response.3,4 The framework for taking a graduated response to a professional lapse begins with fact-finding and documentation. The investigation should determine the validity of the report(s) about unprofessional behavior; characterize its frequency, severity, and/or longevity; and identify its underlying causes. If the complaint is severe and appears valid, the director may need to schedule a formal process immediately. In other instances when the complaint may be of questionable merit or represents a single occurrence, for example, the director may first arrange an informal discussion with the faculty member to discuss the problem, gain her perspective, provide feedback and thereby educate the faculty member about professionalism, and even suggest some corrective actions, as warranted. If the faculty member’s behavior persists and becomes a pattern, the director should hold more prescriptive sessions and craft a remediation plan with/for the faculty member. Depending on the nature of the lapse and its causes, the plan could range from awareness training, anger management seminars, and/or behavioral monitoring to participation in physician health programs.1,3,4 If the faculty member fails to comply with the remediation plan and/or correct the problematic behavior, the director (following due process) may need to relieve the faculty member from her responsibility for teaching residents.
Consider a “professionalism error approach” to lapses. A promising approach to responding to professional lapses parallels the process for addressing medical errors.5 The goal of this model is to understand lapses, educate to correct lapses, and eventually prevent them—not to punish them. In contrast to a more conventional method, the professionalism error model views a lapse not as a character flaw, but as something that can happen to good people.
It addresses a lapse through using root cause analysis to identify the role that deficits in knowledge, judgment, skill, and systems play in the occurrence of a lapse. It also provides training to remove those deficits, for example, in active listening, empathy, and conflict negotiation. In short, this approach holds the faculty member blameless, until proven otherwise, and offers support for coaching him toward success.5
Conduct difficult conversations successfully. Throughout the process, the residency director will need to talk with a variety of individuals about the residents’ report—the faculty member, the residents themselves, perhaps operating room staff, and the department chair. The interchanges could be difficult, marked by differences of opinion, strong emotion, and possibly high stakes. By adopting techniques described in Crucial Conversations,6,7 the director can dialogue with all of these individuals to resolve the issue successfully. The keys to dialogue are watching for participants’ attacks or retreats to silence during the conversation and making it safe for all by asking questions and eliciting others’ viewpoints, even opposing ones. If the director states facts first, tentatively explains what she is beginning to conclude, and asks others to do the same, shared meaning and satisfying action can result.
Summary. To respond effectively to a professional lapse of a faculty member teaching residents, the residency director should exercise his authority, follow due process, take a graduated approach to the lapse, consider using a medical error model, and adopt communication techniques appropriate to difficult conversations.
Coda. Before the director faces the need to respond to a faculty member’s unprofessional behavior, she should work with her chair and colleagues to be sure that the department has a comprehensive professionalism policy containing the major points presented above.
- Sullivan C, Arnold L. Assessment and remediation in programs of teaching professionalism. In R. Cruess, S. Cruess, Y. Steinert, eds. Teaching Medical Professionalism. Cambridge, England and New York, NY: Cambridge University Press, 2008.
- Accreditation Council for Graduate Medical Education. ACGME Surgery Program Requirements. General Surgery Section II.A.4. Program Personnel and Resources, Program Director. Available at http://www.acgme.org/acWebsite/RRC_440/440_pr Index.asp. Accessed September 12, 2008.
- Arnold L. Responding to the professionalism of learners and faculty in orthopedic surgery. Clin Orthop Relat Res. 2006;449:205-213.
- Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82:1040-1048.
- Ledford CH. Faculty’s Unprofessional Behavior: How to Address It Using an Error Approach. Regional Meeting of the Central Group on Educational Affairs, Columbus, OH, 2008. Available at: http://cgea.net/pres4.12.08/CGEAcledford4.12.08.pdf. Accessed September 11, 2008.
- Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations. New York, NY: McGraw Hill, 2002.
- Marcdante K. Conversing about Unprofessional Behavior. Regional Meeting of the Central Group on Educational Affairs, Columbus, OH, 2008. Available at: http://cgea.net/pres4.12.08/CGEAcledford4.12.08.pdf. Accessed September 15, 2008.