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incident. This could be an isolated event and unlikely to recur or the first observa-
tion of a pattern of behavior. The first report of such behavior is the subject of an
informal “cup of coffee” conversation and treated as an anomaly unless it recurs
[ 27 ]. If the behavior is repeated, then the next step is a confidential nonpunitive
awareness intervention, followed by an authority intervention if problems continue,
and finally there is a disciplinary action by the highest level of administration [ 27 ].
About 60% of physicians improve after level 1 interventions, and recidivism is less
than 2%. Another 20% require additional authority interventions to improve [ 27 ].
At each intervention, the program director or chair should describe the specific
problem behavior and the expected behavior and set a timeline for improvement
with consequences for failure to improve. The responsibility for improvement rests
with the individual resident or other physician. While each intervention is docu-
mented if this is a single incident that is not repeated, the supervisor may choose to
remove the documentation from the physician’s permanent file.
In the course of the intervention, unprofessional behavior should be described in
nonjudgmental language that focuses on the behavior and not on personality. For
example, if a resident is described as driving the nurses and other residents crazy to
the extent that everyone groans when he or she appears and breathes a sigh of relief
when they rotate off service, then this resident is behaving in a manner that creates
divisiveness and is disruptive to team function. This is a deficiency in the ACGME
competencies of both interpersonal skills and communication skills as well as
systems- based practice because of the impact on team function. Therefore, it should
be described as such with specific examples. If the resident is manipulative, gets oth-
ers to do his/her work, shows up late for assigned activities, and/or is delinquent in
administrative tasks, then this resident is exhibiting a deficiency in the ACGME
competency of professionalism. Finally, if patient care is impacted by a delay in
communications/poor follow through/team dysfunction, then this is an obvious defi-
ciency in the ACGME competency of patient care. Sometimes supervising physi-
cians are the last to hear about clinical performance problems because the natural
response of residents is to fill in these gaps in patient care themselves. Therefore, the
nurses and administrative staff are frequently a more reliable source of information.
There are some guiding principles for addressing unprofessional behavior that
include setting very clear expectations as to what is meant by professional behavior,
modeling such behavior, and holding all accountable. Some specific interventions
that are worth suggesting include encouraging self-reflection in order to gain insight,
increasing self-awareness through feedback from nurses or others with whom the
individual resident works so the message is presented from different sources, and
structured mentoring [ 24 ].
There is a spectrum of unprofessional behavior that runs from a single unprofes-
sional event at the less serious end of the spectrum to misconduct at the most
extreme. Determining whether to call such behaviors unprofessional or misconduct
is often at the discretion of the chair or program director. However, the difference is
important as the consequences for misconduct are more severe. By definition, mis-
conduct is a behavior that is wrong, that one knows (or should know) is wrong, and
therefore will not be cured by remediation. One approach to assigning culpability is
H. Sanfey