2014, 36: 621–625
Unprofessional behavior by specialty: A qualitative analysis of six years of student perceptions of medical school faculty NICOLE K. ROBERTS, J. KEVIN DORSEY & BRITTANY WOLD Southern Illinois University School of Medicine, USA
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Abstract Background: Unprofessional behavior has well documented negative effects both on the clinical care environment and on the learning environment. If unprofessional behavior varies by department or specialty, this has implications both for faculty development and for undergraduate and graduate level training. Aims: We sought to learn which unprofessional behaviors were endemic in our school, and which were unique to particular departments. Methods: Students graduating from medical school between 2007 and 2012 were asked to complete a questionnaire naming the most professional and least professional faculty members they encountered in during school. For the least professional faculty members, they were also asked to provide information about the unprofessional behavior. Results: Students noted several types of unprofessional behavior regardless of the department faculty were in; however, there were some behaviors only noted in individual departments. The unprofessional behavior profiles for Surgery and Obstetrics/ Gynecology were markedly similar, and were substantially different from all other specialties. Conclusion: Undergraduate, graduate, and faculty education focused on unprofessional behavior that may occur in various learning environments may provide a feasible, practical, and an effective approach to creating a culture of professional behavior throughout the organization.
Introduction
Practice points
Numerous authors have studied what constitutes professionalism in medicine and what constitutes a lack of professionalism. When discussing unprofessional behavior, most describe rudeness and disrespect for others, various violations of appropriate communication rules, and breaches of trust with patients (Ginsburg et al. 2002; Robins et al. 2002; Kaldjian et al. 2012; Rogers et al. 2012). Developing categories for professional and unprofessional behavior allows professionals to come to consensus on what behaviors are deemed acceptable or unacceptable in their realms. The effects of unprofessional behavior in medicine are well documented, and include the perception of poor clinical outcomes, lower patient satisfaction, increased recruiting costs and lower employee satisfaction (Rosenstein & O’Daniel 2005a,b; Rosenstein 2011; Reiter et al. 2012). Further, unprofessional behavior is perpetuated when learners and colleagues observe faculty behaving poorly (Gino et al. 2009). The learning environment is also adversely affected by unprofessional behavior through faculty’s failure to model and therefore to teach aspects of professionalism or by undermining the stated goals of the curriculum (Ephgrave et al. 2006; Chuang et al. 2010; Byszewski et al. 2012).
Students notice faculty unprofessional behaviors. Students are especially attuned to disrespectful behaviors, noticing those most frequently. Unprofessional behaviors may differ, depending on department. Knowing what unprofessional behaviors occur in various environments can guide interventions.
Unprofessional behaviors are serious enough to warrant disciplinary action by state review boards that have been analyzed with respect to demographic characteristics including medical specialty. These behaviors included substance abuse, sexual misconduct and inappropriate prescribing (Talbott et al. 1987; Bloom et al. 1989; Dehlendorf & Wolfe 1998; Morrison & Wickersham 1998). Others have examined less serious disruptive behaviors and found them to be more common in surgical specialties (Rosenstein & O’Daniel 2008; Goettler et al. 2011). This raises the question whether some specialties are more at risk for certain unprofessional behaviors and, if so, what are the implications for training in these specialties.
Correspondence: Nicole K. Roberts, PhD, Department of Medical Education, Academy for Scholarship in Education, Southern Illinois University School of Medicine, PO Box 19681, Springfield, IL 62794-9681, USA. Tel: (217) 545-2103; Fax: (217) 545-0210; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/70621–5 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.899690
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One realm that has not been broached is the relationship between type of specialty and kind of unprofessional behavior. In this paper, we focus on day-to-day behaviors that set the tone for the practice, that communicate the norms, the hidden curriculum. These are behaviors that may go unremarked by the culture but are noticed by students and cause them consternation, or worse-imprinting. Addressing the relationship between specialty and unprofessional behavior would allow for differential approaches to training based on likely problems – that is, rather than approaching professionalism and lack thereof from a ‘‘one size fits all’’ perspective, it would allow educators to prospectively sensitize trainees to the manifestations of unprofessional behavior they may fall subject to, and give them tools to avoid developing poor behaviors. It would also allow the prospective notice and training of faculty in various environments to prevent likely unprofessional behaviors which in turn could lead to a culture of constant professionalism. Here, we elaborate on the qualitative aspect of a previously reported study (Dorsey et al. in press). We propose an answer to the question: Do different specialty types manifest unprofessional behavior in characteristic ways? And if so, what are the implications for training and faculty development?
Methods We asked students in the classes of 2007–2012 to complete a questionnaire just prior to the graduation (n ¼ 385/415, 92% response rate). Students were asked to complete the questionnaire independently and anonymously, without discussing with their colleagues, using the American Board of Internal Medicine definition of professional behavior as a reference. Students were asked to name the most professional and the least professional faculty members they observed in each of nine departments (Basic sciences in year 1, Basic Sciences in year 2, Family and Community Medicine (FCM), Internal Medicine (IM), Pediatrics, Psychiatry, Neurology, Surgery and Obstetrics/Gynecology (OB-GYN)). Students could name as few or as many faculty members as most or least professional in each department as they chose. They were then asked to describe the unprofessional behavior and/or to make recommendations for behavior improvement. The comments the students generated are the data that inform this study. We used Atlas.ti (2013) to support the qualitative analysis of student comments. Atlas.ti allows the user to create codes to describe qualitative data, assess and understand the relationships among the codes and within the data, and inductively create theory to explain the data. Data can then be represented using a network view that allows the researcher to create relationships among codes. In our case, we created networks to demonstrate similarities and differences among departments in their unprofessional behavior. To develop these networks, we first coded student comments for demographic information (year, department of the faculty member, a code number for each individual faculty member). We then characterized each with descriptive codes to capture the behavior or problem the students identified. Each comment could receive multiple codes, depending on student description of behavior. 622
Two researchers independently coded the full set of student comments for each year. We met three times to review and come to an agreement on how to code each comment. We used Atlas.ti to create network views showing the relationships among the codes. We elected to have three levels of codes: central codes, which describe the overarching theme that is represented by the next level of codes. Secondary codes are ‘‘included’’ in the central codes. Codes at the third level provide examples of the second level code. Thus in the first network, all group unprofessional behavior includes deficits in teaching and deficits in interactional style. Examples of deficits in teaching are biased evaluation, poor teaching style, etc. Although it is possible to create as many connections as the user wants, the information we intended to communicate was the behavior students noticed in various places. The relationships among the examples of unprofessional behavior (for instance) would serve to complicate the network view unnecessarily.
Results A total of 874 comments described the unprofessional behavior of 177 individual faculty members. One hundred twentyseven faculty were not cited once for unprofessional behavior during the six-year study period. Seventy-eight descriptive codes were created and used for a total of 1749 codings, as each comment could receive multiple codes. This study was reviewed by the Springfield Committee on Research in Human Subjects (the local institutional review board) and considered exempt. We created a table of co-occurring codes using Atlas.ti. Using this table, it was possible to determine which codes occurred across all departments with relatively equal frequency, and which codes occurred more exclusively or preponderantly within individual specialties. In order to be included in a network, a code had to have occurred at least four times. We then used Atlas.ti to construct network views demonstrating the relationships among the codes. Networks were reviewed by faculty during a school-wide educational symposium and in departmental meetings. Faculty viewed them as troubling but generally accurate. Over the course of the study, individuals who were mentioned most frequently were given feedback by the Dean or their department chair. Figure 1 depicts the profile of unprofessional behaviors that appear throughout the school. Codes were selected because each of them was noticed in at least eight of the nine departments in the School of Medicine. We categorized the behaviors as [codes are capitalized for clarity] deficits in teaching and deficits in interactional style. The deficits in teaching students noticed throughout the educational environment were biased evaluation, poor teaching style, ignoring teaching responsibilities, and poor feedback. One behavior, disrespecting students/residents, was a combination of a deficit in teaching and a deficit in interactional style. Deficits in interactional style noticed throughout the school included denigrating/disrespecting colleagues, being rude/demeaning, being arrogant/condescending/lacking humility, being overly familiar, being moody/petty, jokes/insensitive comments,
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Unprofessional behavior by specialty
Figure 1. School-wide unprofessional behaviors.
Table 1. Examples of school-wide unprofessional behavior comments.
Code Biased evaluation Poor teaching style Ignoring teaching responsibility Disrespecting students/Residents Disrespecting/Denigrating colleagues Being rude/Demeaning Being arrogant/Condescending/ Lacking humility Overly familiar
Being moody/Petty Jokes/Insensitive comments Argumentative Harsh interaction style
Exemplar comment Allows personal opinion to keep from adequately and fairly evaluating students. Not objective. Probably the worst teacher I have ever encountered. Blatant disregard to students’ questions/concerns. Fixed in beliefs. Won’t change ‘‘lecture’’ or teaching style despite overwhelming negative feedback. Completely uninterested in teaching students. He was extremely sarcastic and unavailable for questions. All [subject matter] taught by him I learned with help from another Dr. On occasion, he acted like medical students’ and residents’ sole purpose was to serve him. At those times, there was no teaching but only scut work for him. He spoke negatively of many of his colleagues. He would often provide his opinion as fact and immediately disregard any other opinions. Always rude to students, harsh -personality and reputation precedes him from other students and department faculty and staff at [two clinical sites] as an unprofessional doc who is rude to patients, students, and staff. Arrogant, paternalistic. All around unprofessional. Poor manners with patients. Disrespectful to ancillary staff. Condescending demeanor to students. Horribly unpleasant to be around in stressful situations. She is a good teacher and she knows the material. However, I feel that she often gets too involved in the personal lives of students. My suggestion for her would be to take less of ‘‘friend’’ role and more of an ‘‘instructor’’ role. Very irritable, moody, residents/students subject to daily changes in attitude. Dr. has a sense of humor where he likes to make fun of people, which can seem a little unpalatable at times. Makes morning report and grand rounds a pain. He’s argumentative and uses every opportunity to showboat/get on his soapbox. Aggressive attitude, frequently refused to let me see clinic patients with her, poor interactions with patients.
being argumentative and harsh interaction style. Therefore, all of these behaviors are included in the overall portrait of unprofessional behavior at our school. Comments related exclusively to clinical performance were never cited by students for basic science faculty. Exemplar comments are in Table 1. In addition to those global behaviors, some behaviors were found only in the clinical setting. For example, students
noticed disrespecting patients and families in all clinical departments and inappropriate management of patient interaction in all clinical departments but one.
The exceptions The unprofessional behavior profile of OB-GYN and Surgery looked substantially similar to one another, and quite different from the other specialties. Their behavioral profile was
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Figure 2.
Surgery and OB-GYN unprofessional behaviors.
characterized by the broad themes of patient care related behaviors, rule breaking, and violence/mistreatment. Each broad theme is characterized by several codes. Figure 2 depicts the Surgery-OB/GYN profile. Each of the behaviors identified was preponderant in these two departments compared to all the others. Patient care-related behaviors tended to be some form of benign neglect or lack of compassion, either for the patient or the family of the patient. Rule breaking behaviors were relatively minor, petty offenses that seemed discordant to the students mentioning them, but were unlikely to cause true harm to patients or to the students. Violence/mistreatment ran the gamut, from throwing things, hitting and pushing and threatening, to being cold and uncaring to patients. It is important to note that these egregious unprofessional behaviors were rare – hitting or pushing, for instance, happened five times over the course of the six-year study. Nevertheless, those behaviors only occurred in Surgery and Obstetrics and Gynecology.
Conclusion Based on comparison to other medical schools, SIU School of Medicine’s educational environment fares well. For example, 624
on the AAMC Graduation Questionnaire during 2007–2012 for the question ‘‘Overall I am satisfied with the quality of my medical education’’ answered on a 5-point Likert with 5 ¼ strongly agree, SIU averaged 4.43 compared to all schools rating of 4.25. For the question ‘‘Have you personally been mistreated during medical school?’’ answered Y/N, SIU had 9.1% yes compared to all schools 16.4% yes. We believe, though, that there is always room for improvement, thus we undertook this study. While students notice some unprofessional behaviors regardless of the learning environment, there are other unprofessional behaviors they observe only in specific learning environments. These observations have implications for training and faculty development. At Southern Illinois University School of Medicine, and perhaps most schools, the entire faculty would be well served by having faculty development that emphasizes interacting with learners in an appropriately respectful manner and addresses how to provide feedback and evaluation constructively. This combined with one-on-one feedback for those who are identified as behaving unprofessionally (Dorsey et al. in press) is likely to have a positive impact on the professional environment of the school. The profile of OB-GYN and Surgery is striking in its difference from the other specialties. The behaviors students
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Unprofessional behavior by specialty
noticed there, including mistreatment of patients, staff, and students, and the violent type behaviors, suggest that faculty members may be under a unique stress that elicits behaviors not normally seen in other places. It may be beneficial to evaluate specific environments to determine which stressors can be minimized or eliminated. In addition, it may be that faculty in these specialties with their high pressured practices could be well served by some faculty development in stress management and in communication. Further study is warranted to illuminate this issue. It is important to emphasize, though, that the unprofessional behaviors the students noted are not acceptable approaches to coping with problems in the environment. The observations in this paper also suggest that in addition to working with faculty, training programs would be well advised to address stress management and communication with learners in the procedural specialties. Although this six-year study took place in one institution, we believe it is informative for other institutions. Some categories of behavior may be unique to our institution; however, most of the categories of unprofessional behavior are familiar and we suspect present in other institutions. Of special note, it is highly likely that our portrait of Surgery and OB-GYN will be instructive to others, and thus can guide approaches to faculty development and training of learners in the procedural specialties and subspecialties. It could be argued that students expect the untoward behavior they noted in Surgery and OB-GYN, and thus the real reason those specialties look different from the others is that students expect and notice stereotypic behaviors from faculty in those specialties. However, it is also the case that the behaviors they noticed did, in fact, occur in those environments and the students did not notice such behaviors in other learning environments. It is likely that had the behaviors occurred in other environments, they would have been even more notable, and thus even more likely to be commented upon. By analyzing student-noted unprofessional behavior both on a school-wide basis and on a department-by-department basis, we provide guidance into how an institution might approach faculty development intended to improve the professional culture. It is likely to be unnecessary, for instance, to target faculty development intended to improve temperamental behaviors toward basic sciences departments or toward FCM. These would be more useful for Surgery and OB-GYN. However, it would be warranted to offer programs intended to guide interactions with learners to the whole school. Programs focused on providing effective feedback would also be useful for the faculty at large. Effectively targeting interventions, in addition to addressing individual faculty members whose behavior is noted, makes culture change a distinct possibility.
Notes on contributors Dr. Nicole K. Roberts, PhD, is an Associate Professor in the Department of Medical Education, and Director of Academy for Scholarship in Education Southern Illinois University School of Medicine. Dr. J. Kevin Dorsey, MD, PhD, is the Dean and Provost of Southern Illinois University School of Medicine.
Dr. Brittany Wold, MD, is a Resident Physician of Department of Pediatrics, Southern Illinois University School of Medicine.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References Atlas.ti (Version 7.0.83). 2013. Berlin, Germany: Atlas.ti GmbH. Bloom JD, Williams MH, Kofoed L, Rhyne C, Resnick M. 1989. The malpractice claims experiences of physicians investigated for inappropriate prescribing. Western J Med 151(3):336–338. Byszewski A, Hendelman W, McGuinty C, Moineau G. 2012. Wanted: Role models – Medical students’ perceptions of professionalism. BMC Med Educ 12:115. doi: 10.1186/1472-6920-12-115. Chuang AW, Nuthalapaty FS, Casey PM, Kaczmarczyk JM, Cullimore AJ, Dalrymple JL, Dugoff L, Espey EL, Hammoud MM, Hueppchen NA, et al. 2010. To the point: Reviews in medical education-taking control of the hidden curriculum. Am J Obstetr Gynecol 203(4):316.e1–6. Dehlendorf CE, Wolfe SM. 1998. Physicians disciplined for sex-related offenses. JAMA 279(23):1883–1888. Dorsey JK, Roberts NK, Wold, B. in press. Feedback matters: The impact of an intervention by the dean on unprofessional faculty at one medical school. Acad Med. Ephgrave K, Stansfield RB, Woodhead J, Sharp WJ, George T, Lawrence J. 2006. The resident view of professionalism behavior frequency in outstanding and ‘‘not outstanding’’ faculty. Am J Surgery 191(5):701–705. Gino F, Ayal S, Ariely D. 2009. Contagion and differentiation in unethical behavior: The effect of one bad apple on the barrel. Psychol Sci 20(3):393–398. Ginsburg S, Regehr G, Stern D, Lingard L. 2002. The anatomy of the professional lapse: Bridging the gap between traditional frameworks and students’ perceptions. [Research Support, Non-U.S. Gov’t]. Acad Med 77(6):516–522. Goettler CE, Butler TS, Shackleford P, Rotondo MF. 2011. Physician behavior: Not ready for ‘Never’land. [Comparative Study]. Am Surg 77(12):1600–1605. Kaldjian LC, Rosenbaum ME, Shinkunas LA, Woodhead JC, Antes LM, Rowat JA, Forman-Hoffman VL. 2012. Through students’ eyes: Ethical and professional issues identified by third-year medical students during clerkships. [Research Support, Non-U.S. Gov’t]. J Med Ethics 38(2):130–132. Morrison J, Wickersham P. 1998. Physicians disciplined by a state medical board. JAMA 279(23):1889–1893. Reiter CE, Pichert JW, Hickson G. 2012. Addressing behavior and performance issues that threaten quality and patient safety: What your attorneys want you to know. Prog Ped Card 33:37–45. Robins LS, Braddock 3rd CH, Fryer-Edwards KA. 2002. Using the American Board of Internal Medicine’s ‘‘Elements of Professionalism’’ for undergraduate ethics education. [Evaluation Studies Research Support, NonU.S. Gov’t]. Acad Med 77(6):523–531. Rogers DA, Boehler ML, Roberts NK, Johnson V. 2012. Using the hidden curriculum to teach professionalism during the surgery clerkship. J Surg Educ 69(3):423–427. Rosenstein AH. 2011. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual 26(5):372–379. Rosenstein AH, O’Daniel M. 2005a. Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. Am J Nurs 105(1):54–64. Rosenstein AH, O’Daniel M. 2005b. Study links disruptive behavior to negative patient outcomes. [Interview]. OR Manager 21(3):1, 20, 22. Rosenstein AH, O’Daniel M. 2008. Invited article: Managing disruptive physician behavior: impact on staff relationships and patient care. Neurology 70(17):1564–1570. Talbott GD, Gallegos KV, Wilson PO, Porter TL. 1987. The Medical Association of Georgia’s Impaired Physicians Program. Review of the first 1000 physicians: Analysis of specialty. [Research Support, Non-U.S. Gov’t]. JAMA 257(21):2927–2930.
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Unprofessional behavior by specialty: A qualitative analysis of six years of student perceptions of medical school faculty NICOLE K. ROBERTS, J. KEVIN DORSEY & BRITTANY WOLD Southern Illinois University School of Medicine, USA
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Abstract Background: Unprofessional behavior has well documented negative effects both on the clinical care environment and on the learning environment. If unprofessional behavior varies by department or specialty, this has implications both for faculty development and for undergraduate and graduate level training. Aims: We sought to learn which unprofessional behaviors were endemic in our school, and which were unique to particular departments. Methods: Students graduating from medical school between 2007 and 2012 were asked to complete a questionnaire naming the most professional and least professional faculty members they encountered in during school. For the least professional faculty members, they were also asked to provide information about the unprofessional behavior. Results: Students noted several types of unprofessional behavior regardless of the department faculty were in; however, there were some behaviors only noted in individual departments. The unprofessional behavior profiles for Surgery and Obstetrics/ Gynecology were markedly similar, and were substantially different from all other specialties. Conclusion: Undergraduate, graduate, and faculty education focused on unprofessional behavior that may occur in various learning environments may provide a feasible, practical, and an effective approach to creating a culture of professional behavior throughout the organization.
Introduction
Practice points
Numerous authors have studied what constitutes professionalism in medicine and what constitutes a lack of professionalism. When discussing unprofessional behavior, most describe rudeness and disrespect for others, various violations of appropriate communication rules, and breaches of trust with patients (Ginsburg et al. 2002; Robins et al. 2002; Kaldjian et al. 2012; Rogers et al. 2012). Developing categories for professional and unprofessional behavior allows professionals to come to consensus on what behaviors are deemed acceptable or unacceptable in their realms. The effects of unprofessional behavior in medicine are well documented, and include the perception of poor clinical outcomes, lower patient satisfaction, increased recruiting costs and lower employee satisfaction (Rosenstein & O’Daniel 2005a,b; Rosenstein 2011; Reiter et al. 2012). Further, unprofessional behavior is perpetuated when learners and colleagues observe faculty behaving poorly (Gino et al. 2009). The learning environment is also adversely affected by unprofessional behavior through faculty’s failure to model and therefore to teach aspects of professionalism or by undermining the stated goals of the curriculum (Ephgrave et al. 2006; Chuang et al. 2010; Byszewski et al. 2012).
Students notice faculty unprofessional behaviors. Students are especially attuned to disrespectful behaviors, noticing those most frequently. Unprofessional behaviors may differ, depending on department. Knowing what unprofessional behaviors occur in various environments can guide interventions.
Unprofessional behaviors are serious enough to warrant disciplinary action by state review boards that have been analyzed with respect to demographic characteristics including medical specialty. These behaviors included substance abuse, sexual misconduct and inappropriate prescribing (Talbott et al. 1987; Bloom et al. 1989; Dehlendorf & Wolfe 1998; Morrison & Wickersham 1998). Others have examined less serious disruptive behaviors and found them to be more common in surgical specialties (Rosenstein & O’Daniel 2008; Goettler et al. 2011). This raises the question whether some specialties are more at risk for certain unprofessional behaviors and, if so, what are the implications for training in these specialties.
Correspondence: Nicole K. Roberts, PhD, Department of Medical Education, Academy for Scholarship in Education, Southern Illinois University School of Medicine, PO Box 19681, Springfield, IL 62794-9681, USA. Tel: (217) 545-2103; Fax: (217) 545-0210; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/70621–5 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.899690
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One realm that has not been broached is the relationship between type of specialty and kind of unprofessional behavior. In this paper, we focus on day-to-day behaviors that set the tone for the practice, that communicate the norms, the hidden curriculum. These are behaviors that may go unremarked by the culture but are noticed by students and cause them consternation, or worse-imprinting. Addressing the relationship between specialty and unprofessional behavior would allow for differential approaches to training based on likely problems – that is, rather than approaching professionalism and lack thereof from a ‘‘one size fits all’’ perspective, it would allow educators to prospectively sensitize trainees to the manifestations of unprofessional behavior they may fall subject to, and give them tools to avoid developing poor behaviors. It would also allow the prospective notice and training of faculty in various environments to prevent likely unprofessional behaviors which in turn could lead to a culture of constant professionalism. Here, we elaborate on the qualitative aspect of a previously reported study (Dorsey et al. in press). We propose an answer to the question: Do different specialty types manifest unprofessional behavior in characteristic ways? And if so, what are the implications for training and faculty development?
Methods We asked students in the classes of 2007–2012 to complete a questionnaire just prior to the graduation (n ¼ 385/415, 92% response rate). Students were asked to complete the questionnaire independently and anonymously, without discussing with their colleagues, using the American Board of Internal Medicine definition of professional behavior as a reference. Students were asked to name the most professional and the least professional faculty members they observed in each of nine departments (Basic sciences in year 1, Basic Sciences in year 2, Family and Community Medicine (FCM), Internal Medicine (IM), Pediatrics, Psychiatry, Neurology, Surgery and Obstetrics/Gynecology (OB-GYN)). Students could name as few or as many faculty members as most or least professional in each department as they chose. They were then asked to describe the unprofessional behavior and/or to make recommendations for behavior improvement. The comments the students generated are the data that inform this study. We used Atlas.ti (2013) to support the qualitative analysis of student comments. Atlas.ti allows the user to create codes to describe qualitative data, assess and understand the relationships among the codes and within the data, and inductively create theory to explain the data. Data can then be represented using a network view that allows the researcher to create relationships among codes. In our case, we created networks to demonstrate similarities and differences among departments in their unprofessional behavior. To develop these networks, we first coded student comments for demographic information (year, department of the faculty member, a code number for each individual faculty member). We then characterized each with descriptive codes to capture the behavior or problem the students identified. Each comment could receive multiple codes, depending on student description of behavior. 622
Two researchers independently coded the full set of student comments for each year. We met three times to review and come to an agreement on how to code each comment. We used Atlas.ti to create network views showing the relationships among the codes. We elected to have three levels of codes: central codes, which describe the overarching theme that is represented by the next level of codes. Secondary codes are ‘‘included’’ in the central codes. Codes at the third level provide examples of the second level code. Thus in the first network, all group unprofessional behavior includes deficits in teaching and deficits in interactional style. Examples of deficits in teaching are biased evaluation, poor teaching style, etc. Although it is possible to create as many connections as the user wants, the information we intended to communicate was the behavior students noticed in various places. The relationships among the examples of unprofessional behavior (for instance) would serve to complicate the network view unnecessarily.
Results A total of 874 comments described the unprofessional behavior of 177 individual faculty members. One hundred twentyseven faculty were not cited once for unprofessional behavior during the six-year study period. Seventy-eight descriptive codes were created and used for a total of 1749 codings, as each comment could receive multiple codes. This study was reviewed by the Springfield Committee on Research in Human Subjects (the local institutional review board) and considered exempt. We created a table of co-occurring codes using Atlas.ti. Using this table, it was possible to determine which codes occurred across all departments with relatively equal frequency, and which codes occurred more exclusively or preponderantly within individual specialties. In order to be included in a network, a code had to have occurred at least four times. We then used Atlas.ti to construct network views demonstrating the relationships among the codes. Networks were reviewed by faculty during a school-wide educational symposium and in departmental meetings. Faculty viewed them as troubling but generally accurate. Over the course of the study, individuals who were mentioned most frequently were given feedback by the Dean or their department chair. Figure 1 depicts the profile of unprofessional behaviors that appear throughout the school. Codes were selected because each of them was noticed in at least eight of the nine departments in the School of Medicine. We categorized the behaviors as [codes are capitalized for clarity] deficits in teaching and deficits in interactional style. The deficits in teaching students noticed throughout the educational environment were biased evaluation, poor teaching style, ignoring teaching responsibilities, and poor feedback. One behavior, disrespecting students/residents, was a combination of a deficit in teaching and a deficit in interactional style. Deficits in interactional style noticed throughout the school included denigrating/disrespecting colleagues, being rude/demeaning, being arrogant/condescending/lacking humility, being overly familiar, being moody/petty, jokes/insensitive comments,
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Unprofessional behavior by specialty
Figure 1. School-wide unprofessional behaviors.
Table 1. Examples of school-wide unprofessional behavior comments.
Code Biased evaluation Poor teaching style Ignoring teaching responsibility Disrespecting students/Residents Disrespecting/Denigrating colleagues Being rude/Demeaning Being arrogant/Condescending/ Lacking humility Overly familiar
Being moody/Petty Jokes/Insensitive comments Argumentative Harsh interaction style
Exemplar comment Allows personal opinion to keep from adequately and fairly evaluating students. Not objective. Probably the worst teacher I have ever encountered. Blatant disregard to students’ questions/concerns. Fixed in beliefs. Won’t change ‘‘lecture’’ or teaching style despite overwhelming negative feedback. Completely uninterested in teaching students. He was extremely sarcastic and unavailable for questions. All [subject matter] taught by him I learned with help from another Dr. On occasion, he acted like medical students’ and residents’ sole purpose was to serve him. At those times, there was no teaching but only scut work for him. He spoke negatively of many of his colleagues. He would often provide his opinion as fact and immediately disregard any other opinions. Always rude to students, harsh -personality and reputation precedes him from other students and department faculty and staff at [two clinical sites] as an unprofessional doc who is rude to patients, students, and staff. Arrogant, paternalistic. All around unprofessional. Poor manners with patients. Disrespectful to ancillary staff. Condescending demeanor to students. Horribly unpleasant to be around in stressful situations. She is a good teacher and she knows the material. However, I feel that she often gets too involved in the personal lives of students. My suggestion for her would be to take less of ‘‘friend’’ role and more of an ‘‘instructor’’ role. Very irritable, moody, residents/students subject to daily changes in attitude. Dr. has a sense of humor where he likes to make fun of people, which can seem a little unpalatable at times. Makes morning report and grand rounds a pain. He’s argumentative and uses every opportunity to showboat/get on his soapbox. Aggressive attitude, frequently refused to let me see clinic patients with her, poor interactions with patients.
being argumentative and harsh interaction style. Therefore, all of these behaviors are included in the overall portrait of unprofessional behavior at our school. Comments related exclusively to clinical performance were never cited by students for basic science faculty. Exemplar comments are in Table 1. In addition to those global behaviors, some behaviors were found only in the clinical setting. For example, students
noticed disrespecting patients and families in all clinical departments and inappropriate management of patient interaction in all clinical departments but one.
The exceptions The unprofessional behavior profile of OB-GYN and Surgery looked substantially similar to one another, and quite different from the other specialties. Their behavioral profile was
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N.K. Roberts et al.
Figure 2.
Surgery and OB-GYN unprofessional behaviors.
characterized by the broad themes of patient care related behaviors, rule breaking, and violence/mistreatment. Each broad theme is characterized by several codes. Figure 2 depicts the Surgery-OB/GYN profile. Each of the behaviors identified was preponderant in these two departments compared to all the others. Patient care-related behaviors tended to be some form of benign neglect or lack of compassion, either for the patient or the family of the patient. Rule breaking behaviors were relatively minor, petty offenses that seemed discordant to the students mentioning them, but were unlikely to cause true harm to patients or to the students. Violence/mistreatment ran the gamut, from throwing things, hitting and pushing and threatening, to being cold and uncaring to patients. It is important to note that these egregious unprofessional behaviors were rare – hitting or pushing, for instance, happened five times over the course of the six-year study. Nevertheless, those behaviors only occurred in Surgery and Obstetrics and Gynecology.
Conclusion Based on comparison to other medical schools, SIU School of Medicine’s educational environment fares well. For example, 624
on the AAMC Graduation Questionnaire during 2007–2012 for the question ‘‘Overall I am satisfied with the quality of my medical education’’ answered on a 5-point Likert with 5 ¼ strongly agree, SIU averaged 4.43 compared to all schools rating of 4.25. For the question ‘‘Have you personally been mistreated during medical school?’’ answered Y/N, SIU had 9.1% yes compared to all schools 16.4% yes. We believe, though, that there is always room for improvement, thus we undertook this study. While students notice some unprofessional behaviors regardless of the learning environment, there are other unprofessional behaviors they observe only in specific learning environments. These observations have implications for training and faculty development. At Southern Illinois University School of Medicine, and perhaps most schools, the entire faculty would be well served by having faculty development that emphasizes interacting with learners in an appropriately respectful manner and addresses how to provide feedback and evaluation constructively. This combined with one-on-one feedback for those who are identified as behaving unprofessionally (Dorsey et al. in press) is likely to have a positive impact on the professional environment of the school. The profile of OB-GYN and Surgery is striking in its difference from the other specialties. The behaviors students
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Unprofessional behavior by specialty
noticed there, including mistreatment of patients, staff, and students, and the violent type behaviors, suggest that faculty members may be under a unique stress that elicits behaviors not normally seen in other places. It may be beneficial to evaluate specific environments to determine which stressors can be minimized or eliminated. In addition, it may be that faculty in these specialties with their high pressured practices could be well served by some faculty development in stress management and in communication. Further study is warranted to illuminate this issue. It is important to emphasize, though, that the unprofessional behaviors the students noted are not acceptable approaches to coping with problems in the environment. The observations in this paper also suggest that in addition to working with faculty, training programs would be well advised to address stress management and communication with learners in the procedural specialties. Although this six-year study took place in one institution, we believe it is informative for other institutions. Some categories of behavior may be unique to our institution; however, most of the categories of unprofessional behavior are familiar and we suspect present in other institutions. Of special note, it is highly likely that our portrait of Surgery and OB-GYN will be instructive to others, and thus can guide approaches to faculty development and training of learners in the procedural specialties and subspecialties. It could be argued that students expect the untoward behavior they noted in Surgery and OB-GYN, and thus the real reason those specialties look different from the others is that students expect and notice stereotypic behaviors from faculty in those specialties. However, it is also the case that the behaviors they noticed did, in fact, occur in those environments and the students did not notice such behaviors in other learning environments. It is likely that had the behaviors occurred in other environments, they would have been even more notable, and thus even more likely to be commented upon. By analyzing student-noted unprofessional behavior both on a school-wide basis and on a department-by-department basis, we provide guidance into how an institution might approach faculty development intended to improve the professional culture. It is likely to be unnecessary, for instance, to target faculty development intended to improve temperamental behaviors toward basic sciences departments or toward FCM. These would be more useful for Surgery and OB-GYN. However, it would be warranted to offer programs intended to guide interactions with learners to the whole school. Programs focused on providing effective feedback would also be useful for the faculty at large. Effectively targeting interventions, in addition to addressing individual faculty members whose behavior is noted, makes culture change a distinct possibility.
Notes on contributors Dr. Nicole K. Roberts, PhD, is an Associate Professor in the Department of Medical Education, and Director of Academy for Scholarship in Education Southern Illinois University School of Medicine. Dr. J. Kevin Dorsey, MD, PhD, is the Dean and Provost of Southern Illinois University School of Medicine.
Dr. Brittany Wold, MD, is a Resident Physician of Department of Pediatrics, Southern Illinois University School of Medicine.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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