267voluntary, there is still some discrepancy between the 3% who are terminated and
the reported prevalence of unprofessional behavior. Some of these residents might
be successfully remediated; however, it is likely that many graduate without correc-
tion. Some reasons for this include the lack of assessment standards and unproven
remediation options [ 21 – 23 ]. In addition, program directors are often faced with
scanty or conflicting documentation. Frequently, there is inadequate oversight of
trainee performance at the bedside or in clinic by attendings, so problems that are
blatantly obvious to other healthcare professionals are not identified in a timely
manner. Sometimes there is a “halo” effect whereby occasional lapses in profes-
sionalism are tolerated in the surgical resident who is well liked and has excellent
technical skills. Further barriers to accurate evaluation include concern at the antici-
pated appeal process, loss of popularity or role as resident advocate, and possible
retaliation from the resident. Finally, residents are employees who provide an essen-
tial service; therefore, the faculty are reluctant to increase the workload on col-
leagues by removing a resident from clinical duties [ 24 ].
Identification
There are some flags that permit identification of at-risk residents. One single-
institution study identified a number of variables including age at entry older than
29 years, no participation in team sports, and/or a lack of superlative comments in
the dean’s letter as predictors of unsatisfactory outcome [ 19 ]. In a review of letters
of recommendation, Stohl et al. found that comments about excellence in patient
care and interpersonal and communication skills were predictive of the more suc-
cessful residents. On the other hand, applicants at risk were those who were
described as loners, who applied late, and who had letters predominantly from spe-
cialties other than their chosen field [ 25 ]. While these individuals should not be
excluded, extra vigilance might be required. In another single-institution study, 82%
of the problems in resident behavior were identified in first year of training [ 18 ]. In
an internal medicine study, Yao and Wright [ 26 ] noted that 60% of program direc-
tors identified problem residents through critical incident reports, for example, a
patient complaint. In addition, 75% of program directors most frequently became
aware of problem residents because of verbal complaints from the faculty, and only
31% identified problems from written evaluations by the faculty. Because behav-
ioral problems are frequently identified early in training, the first 6-month review is
a time for critical evaluation of new residents; indeed, there is a case for conducting
quarterly reviews of new residents. Any problem arising at any time should be
brought to the attention of the program director.
Remediation
Gerald Hickson and colleagues at Vanderbilt have a successful four-step program
for disruptive physicians [ 27 ]. The authors note that most physicians rarely exhibit
unprofessional behavior, and a small percentage will exhibit a single unprofessional
16 Promoting Professionalism