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on the behavior and morale of all in the workplace. Roberts et al. suggest that in
making decisions about a resident, consideration should be given to whether the
resident’s performance can be improved sufficiently to perform effectively as a
member of the healthcare team and whether this improvement is likely to be sus-
tained in practice as well as during training [ 33 ]. Other considerations are the cost
of remediation in time, effort, and resources, as well as the hidden cost of retaining
a resident in terms of the increased workload on colleagues due to “work-arounds,”
double checking, and low morale. The amount of time spent discussing a resident is
frequently a measure of the severity of the problem! All complaints about a resident
should be taken seriously and fully investigated. Even if the complaint is not made
in writing, it should be documented by the supervisor although it will be up to his/
her discretion to keep the documentation as part of the individual’s permanent file.
If the complaint is valid, then a determination needs to be made about future action
in terms of remediation/termination or probation. If the decision is to remediate or
place the resident on probation, then there has to be a clear action plan and timeline
for reevaluation. Finally, judgments about a physician’s behavior should be fair and
unbiased and not based on personal friendships, dislikes, antagonisms, jurisdic-
tional disagreements, or competitiveness among members of the staff. Invoking dis-
cipline with no option for assistance automatically creates an adversarial relationship
in which the physician becomes invested in justifying the disruptive behaviors. A
program of assistance allows for constructive change to the benefit of the individual
physician, patients, and members of the healthcare delivery system and allows a
return to normal functioning.
Addressing the Climate
The hidden curriculum refers to the parallel, implicit curriculum by which students
acquire the values, norms, and expectations of professional practice. For the most
part, it is taught through role modeling. Most professional value training is acquired
through resident interaction. Furthermore, we know that student values change dur-
ing medical school. There is a conflict between the values that students take with
them into medical school and observed behaviors. For example, the structure of
medical training promotes competitiveness, and the institutional rewards system
recognizes individuals not teams or collaboration, and teaching is often underval-
ued. Furthermore, modern hospital culture is centered outside the patient room. All
of this has a somewhat negative impact on students and also on junior residents.
Although not intended, medical training by its nature can serve to encourage unpro-
fessional behavior among those who already have personalities that are so inclined.
Abusers often have a past history of having been abused themselves. Many medical
students and residents experience abuse during their training in the form of “belit-
tling” or “humiliation” by “malignant” and “egotistical” attendings [ 34 – 36 ]. Those
who survive their hazing experiences can identify with those in power who previ-
ously abused them. Having achieved full status as physicians, some physicians, hav-
ing paid their dues, feel entitled to reenact abuse on others. As has been stated,
H. Sanfey