Unprofessional behaviour of GP residents and its remediation: a qualitative study among supervisors and faculty

Abstract

Background Lapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later practice requires timely identification and remediation. However, appropriate language to describe unprofessional behaviour and its remediation during residency is lacking. Therefore, this exploratory study aims to investigate which behaviours of GP residents are considered unprofessional according to supervisors and faculty, and how remediation is applied. Methods We conducted eight semi-structured focus group interviews with 55 broadly selected supervisors from four Dutch GP training institutes. In addition, we conducted individual semi-structured interviews with eight designated professionalism faculty members. Interview recordings were transcribed verbatim. Data were coded in two consecutive steps: preliminary inductive coding was followed by secondary deductive coding using the descriptors from the recently developed ‘Four I’s’ model for describing unprofessional behaviours as sensitising concepts. Results Despite the differences in participants’ professional positions, we identified a shared conceptualisation in pinpointing and assessing unprofessional behaviour. Both groups described multiple unprofessional behaviours, which could be successfully mapped to the descriptors and categories of the Four I’s model. Behaviours in the categories ‘Involvement’ and ‘Interaction’ were assessed as mild and received informal, pedagogical feedback. Behaviours in the categories ‘Introspection’ and ‘Integrity’, were seen as very alarming and received strict remediation. We identified two new groups of behaviours; ‘Nervous exhaustion complaints’ and ‘Nine-to-five mentality’, needing to be added to the Four I’s model. The diagnostic phase of unprofessional behaviour usually started with the supervisor getting a ‘sense of alarm’, which was described as either a ‘gut feeling’, ‘a loss of enthusiasm for teaching’ or ‘fuss surrounding the resident’. This sense of alarm triggered the remediation phase. However, the diagnostic and remediation phases did not appear consecutive or distinct, but rather intertwined. Conclusions The processes of identification and remediation of unprofessional behaviour in residents appeared to be intertwined. Identification of behaviours related to lack of introspection or integrity were perceived as the most important to remediate. The results of this research provide supervisors and faculty with an appropriate language to describe unprofessional behaviours among residents, which can facilitate timely identification and remediation.

Unprofessional behaviour of GP residents leading to a dismissal dispute: characteristics and outcomes of those who appeal

“…The descriptions of unprofessional behaviours were copied verbatim from the board’s decisions. These descriptions were classified using the definitions of unprofessional behaviour in medical students developed by Mak-Van der Vossen et al [ 22 ], and in line with focus groups among GP training staff by Barnhoorn et al 2021 [ 23 ].…”

Incorporating a situational judgement test in residency selections: clinical, educational and organizational outcomes

“…Professionalism concerns were considered using the 4I framework [ 38 , 39 ], which originated in the undergraduate medical education setting and with minor changes has been shown to be relevant to the PGME settings [ 40 ]. The 4I framework articulates 30 specific unprofessional behaviors and maps these to four categories (involvement, integrity, interaction and introspection).…”

“…The behavioral descriptors provide a guide to the assessors and educators on what to observe and document [ 38 ]. Based on another study [ 40 ], two descriptors were added to the Introspection category; these included absences related to perceived workload complaints (nervous exhaustion) and a nine-to-five mentality. Professionalism concerns were mapped onto the 4I domains and specific behavioral descriptors based upon the documentation in the program and the central PGME office files and the frequency of the specific behaviors recorded in the pre- and post-Casper cohort.…”

Dismissed Psychiatry Residents Who Appeal: Exploring Unprofessional Behavior

“…Psychiatrists were overrepresented in the classical Papadakis study [1] showing that unprofessional behavior in medical school is associated with unprofessional behavior in the future. Unprofessional behavior in residency is associated with an increased risk of disciplinary board measures after graduation and is an important indication for resident remediation or dismissal [2][3][4][5]. However, there is no empirical research conducted after the Papadakis study [1] specifically toward unprofessional behavior in psychiatry residents.…”

“…(3) The specialist knows the limits of his/her own competence and acts within them. (4) The specialist practices medicine according to the usual ethical standards of the profession and takes an active part in professional quality improvement. While the first sentence underscores principles such as honesty, involvement/compassion, transparency, justification, and accountability, the second sentence introduces behavior toward self and others.…”