269to use the reason criteria and ask if the individual intended to cause harm, came to
work impaired, knowingly and unreasonably increased risk, and if another person in
the same situation would act in a similar manner [ 28 ]. All incidents of alleged mis-
conduct should be investigated and a report generated that considers extenuating
circumstances. The individual should be given notice of the charge and an opportu-
nity to be heard, but if found culpable they do not have to be given an opportunity
to repeat misconduct as long as the final decision is made through a process that is
reasonable.
An important component of the interview, particularly where unprofessional
behavior is deemed out of character for that individual, is the identification of pos-
sible contributing factors. Underlying causes include impairment due to substance
abuse or other psychiatric disorders, external life stressors, personality characteris-
tics, lack of training, or system factors. Some of the more common, treatable factors
include transition or separation issues, nervousness, and cultural differences about
what is considered appropriate behavior. More serious problems include external
stressors such as family illness/marital discord and major illness. In a study of medi-
cal students, Dyrbye et al. found a relationship between unprofessional behaviors
and burnout, in that these behaviors were more common in students with burnout
[ 29 ]. A small percentage of individuals will have a significant mental health or sub-
stance abuse problem. However, a doctor-patient relationship does not and should
not exist between a physician and their supervisor; therefore, if there is a need for
referral, this should be made as a request for a “fitness to practice” examination to
employee health/employee assistance or the Physician Wellness Program and not as
a direct patient referral. The Americans with Disabilities Act [ 30 ] mandates that
educators must make reasonable accommodation to ensure that a resident with a
disability can complete the curriculum; however, the resident must ask for accom-
modation before a performance deficiency occurs. Performance problems should be
addressed as a performance or a behavior problem and not as a health issue. For
example, stress must be discussed as it relates to poor performance—not mental
health. In addition, the Americans with Disabilities Act limits when a psychiatric
evaluation can be required and is usually restricted to decisions about fitness to
practice. After such evaluations, the supervisor should receive notification that
appropriate follow-up is occurring but not medical details.
How an individual responds during the feedback intervention provides insight on
their willingness to improve and the extent to which they are prepared to take
responsibility for their own learning and improvement. This response is the most
useful predictor of successful remediation [ 31 ]. The more defensive the recipient
becomes and the more he/she argues, the more likely it is that this person has what
is termed a fixed mindset, i.e., is deficient in practice-based learning and improve-
ment, and these are the individuals who are a challenge to remediate [ 32 ]. Residents
with a “growth” mind-set believe their success is based on hard work and learning,
while those with a “fixed” mind-set attribute their success to innate ability and their
failures to the actions of others. The latter are a challenge to remediate.
If there is no improvement after an intervention, then it is key to follow through
with the previously discussed consequences. Failure to do this has a negative impact
16 Promoting Professionalism