Unprofessional students = bad clinicians

admin · Dec 22, 2005

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I first noticed this story in PM News, so followed it up from USA Today, which was reporting on research in the New England Journal of Medicine I have paraphrased the title from Bad med students, bad docs:

Physicians disciplined by state medical boards were three times more likely to have shown unprofessional behavior while in medical school than those with no discipline records, a study in today's New England Journal of Medicine finds.
"We found that for physicians disciplined by licensing boards, the strongest association in medical school was unprofessional behavior," says Maxine Papadakis, lead author on the study and the dean for student affairs at the University of California-San Francisco medical school.

Researchers looked at such things as how responsibly med students followed up on patient care and their attitudes when taking constructive criticism. The study is the first to link doctor's professionalism in medical school to later bad outcomes when they practice; it gives professors criteria that can serve as early warning signs of trouble, Papadakis says.

The research is important because it will allow great accountability "to the patients we serve," says James Thompson, president and CEO of the Federation of State Medical Boards.

The research supports a growing movement to make professional behavior a requirement for graduation from medical residency programs. In 1999, the Accreditation Council for Graduate Medical Education included professionalism as one of six "core competencies" being phased in by 2006 as a requirement for graduation.

Thompson, the former dean of Wake Forest University School of Medicine in Winston-Salem, N.C., says medical educators have always known intuitively that there was a connection between unprofessional behavior in medical school and later problems. But Papadakis' work "adds science at a time when we're demanding an evidence base for our judgments," Thompson says.

The study examined the medical school history of graduates who were later disciplined by a state medical board from 1990 to 2003 compared with similar students with no history of problems in med school. The schools studied were UCSF, the University of Michigan Medical School in Ann Arbor and Jefferson Medical College in Philadelphia.

Unprofessional behavior covered several traits:

• Irresponsibility included unreliable attendance at clinics and not following up on activities related to patient care. Medical students who showed such irresponsible behavior three or more times were 8.5 times more likely to receive disciplinary action as doctors.

• Those who showed diminished capacity for self-improvement, including failure to accept constructive criticism, argumentativeness and display of poor attitude three or more times were 3.1 times more likely to receive disciplinary action.

• Other forms of behavior associated less strongly with later disciplinary action included immaturity, poor initiative and impaired relationships with students, faculty, nurses or patients.

Together, these traits turned out to be a much stronger predictor of future disciplinary action than more traditional measures such as test scores and grades.

The study is part of a larger movement within the field of medicine to retool itself for a world in which medicine is often done by teams and "I don't know" is an acceptable phrase for a doctor to utter, says Daniel Federman, the retired dean of medical education at Harvard Medical School.

That's in contrast to the all-knowing, paternalistic doctor whom medical schools "not only educated for but selected for," prior to the 1970s, says Jordan Cohen, president of the Association of American Medical Colleges.

That began to change in the 1980s and 1990s. Today, "there's a great deal more emphasis being placed on what we call professionalism, humanistic behavior and ethical issues," Cohen says.

Disciplinary action by a state medical board is rare. Of the 725,000 practicing physicians in the USA, only 0.3% are disciplined each year.

Failing to graduate from medical school is more likely: About one in 20 students wash out for a host of reasons, Federman says.
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USA Today

NEJM Abstract:

Volume 353:2673-2682 December 22, 2005 Number 25
Disciplinary Action by Medical Boards and Prior Behavior in Medical School
Maxine A. Papadakis, M.D., Arianne Teherani, Ph.D., Mary A. Banach, Ph.D., M.P.H., Timothy R. Knettler, M.B.A., Susan L. Rattner, M.D., David T. Stern, M.D., Ph.D., J. Jon Veloski, M.S., and Carol S. Hodgson, Ph.D.

Background Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case–control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school.

Methods The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe).

Results Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior.

Conclusions In this case–control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career.
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admin Administrator Staff Member

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