Stephen Brown, M.D., has witnessed the full gamut of unprofessional behavior throughout his 25-plus-year medical career.
In his experiences across many different institutions, Dr. Brown, chairman of RSNA’s Professionalism Committee, has observed angry outbursts toward subordinates—trainees, nurses, technicians—that undermine team dynamics and jeopardize patient care. He has seen colleagues working under the influence of alcohol and attending physicians berating junior physicians, medical students and nurses in front of their peers. And the list goes on.
“In the course of my career, I have seen blatant cheating and frank plagiarism. I have seen people submit research reports without properly attributing the work,” said Dr. Brown, an assistant professor of radiology at Boston Children’s Hospital and Harvard Medical School. “Talking with my colleagues in and out of radiology, I don’t think my experience is different from anybody else’s. I have also seen innumerable examples of exemplary professionalism, which are, in fact, common. It is crucial not to lose sight of that. I also believe we have seen an overall shift away from tolerance of unprofessional behavior over time.”
Because unprofessional behavior is a real concern, however, experts stress the importance of educating medical students on proper policy and issues they may encounter at the beginning of their careers. Unprofessional behavior during medical school, residency and fellowship training has been linked to subsequent disciplinary action by medical boards, noted Ronald Eisenberg, M.D., J.D., a professor of radiology at Harvard Medical School, attending radiologist at Beth Israel Deaconess Medical Center in Boston and member of the RSNA Professionalism Committee.
“Consequently, educational initiatives fostering professionalism are essential for residency and fellowship training in order to promote high quality patient care,” Dr. Eisenberg said. “Also, professionalism is one of the competencies that residents are required to achieve before taking the new Core and Certifying ABR examinations.”
The American Board of Radiology (ABR), in partnership with the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS), uses six competencies as the framework defining the qualified and competent physician specialist. “Professionalism is definitely one of the most challenging components to teach and evaluate during residency training,” Dr. Eisenberg said.
For residents—and healthcare professionals overall—professionalism is also one of the most necessary components, said Kate Hanneman, M.D., a radiology resident in her final year at the University of Toronto and resident member of the RSNA Professionalism Committee.
“Unprofessional behavior is potentially very harmful to the future careers of trainees, given that such behavior may adversely affect job prospects and/or eligibility to sit for board exams,” Dr. Hanneman said.
In Canada, the Royal College of Physicians and Surgeons has developed a framework for training in Canadian residency programs, which includes professionalism as one of seven roles, Dr. Hanneman said. At the University of Toronto’s radiology residency program, residents receive professionalism instruction in formal didactic lectures, she said.
At Beth Israel Deaconess Medical Center, the program includes reflective practice, in which someone thinks critically about a thought, experience or action with the goal of increasing self-awareness about one’s own values, priorities and learning needs, Dr. Eisenberg said. In the past two years, the institution has incorporated nine reflective exercises into the residency training. “These radiology-specific, case-based sessions are designed to explicitly foster honesty, compassion, respect and professional and personal growth,” Dr. Eisenberg said.
Fortunately, there is no shortage of learning material on professionalism. The ABR developed online modules on ethics and professionalism which are jointly reviewed and maintained by the RSNA Professionalism Committee and the American College of Radiology (ACR) Committee on Ethics, Dr. Brown said. The RSNA Professionalism Committee produces quarterly online, professionalism vignettes covering a wide range of topics that radiologists may encounter. In addition, Web-based professionalism resources are offered by the Academy of Radiology Leadership and Management co-sponsored by RSNA, and the ACR’s Radiology Leadership Institute™. (See sidebar)
Nevertheless, more programs and materials are necessary for radiology to address professionalism education fully, Dr. Brown said. “Strategies to address the issue of impaired and/or incompetent colleagues begin with education to help people identify such behaviors and understand how they undermine care,” he said. “They also include establishing clear, upfront expectations of conduct, facile mechanisms for reporting such behavior and transparent understandings of how such conduct will be managed.”
Disruptive or unprofessional behavior by any healthcare provider creates a suboptimal work environment—and more importantly—places patient safety at risk, said Priscilla Slanetz, M.D., M.P.H., program director of the Radiology Residency Program at Beth Israel Deaconess Medical Center.
“All physicians must remember that they serve as role models for those around them,” Dr. Slanetz said. “Along with reminding each other about being good role models, taking time to reflect on topics related to professionalism can be helpful in keeping professionalism at the forefront. In our residency training program, we hold dedicated sessions four-to-six times each year to discuss a variety of topics related to professional practice.”
Although infrequent, there may be times when a radiologist encounters a colleague who is impaired or no longer possesses an up-to-date skill set, Dr. Slanetz said. A person’s response must be tailored to the situation at hand, she stressed.
“If a patient’s safety is at risk, it is imperative to act immediately to prevent any harm from occurring,” Dr. Slanetz said. “However, in most cases, it is reasonable to speak to your colleague in a private setting. Many times, he or she will be receptive to your feedback and will seek assistance to remedy the situation.”
Personal accountability and apologies for harmful errors are key to promoting safe, patient-centered care, Dr. Brown said. A sincere demonstration of warmth, understanding and concern—and immediate availability—can go a long way toward alleviating potential problems, Dr. Eisenberg added.
“It is important to treat the patient honestly as a mature, intelligent human being, just as you or a member of your family would want to be treated,” Dr. Eisenberg said.
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