271“Today’s abused student is tomorrow’s source of social control as a resident or
attending physician” [ 37 ]. Krizek [ 38 ] writes that the nature of surgical training and
the rigors of practicing surgery are impairing since external stressors can provoke
disruptive behaviors in physicians predisposed to such behavior. Functioning as a
physician places demands on coping skills that are psychologically draining.
Often the greatest challenges are dealing with a system that enables and rewards
unprofessional behaviors which are often goal directed [ 39 , 40 ]. For example, staff
will often work around uncooperative or even abusive residents and will page an
off-call pleasant resident to see a patient or complete a task, thus “rewarding” bad
behavior by allowing the unprofessional individual to sleep through the night undis-
turbed. Clearly we cannot hold our residents to a higher standard of professionalism
than our faculty colleagues. If the faculty achieve their goals by yelling or abusing
the OR/administrative staff, then the residents learn that this is acceptable profes-
sional behavior. Recognizing and addressing such behavior through a system-level
response will increase the likelihood of successful remediation.
A lack of documentation is often presented as a reason for not dealing more
strictly with unprofessional behavior. However, at least with regard to residents and
students, the courts have unfailingly confirmed that as long as the individual was
provided with “notice and an opportunity to cure and the faculty decision regarding
termination or probation or extension of training is conscientious and deliberate,”
they will not second-guess the academic decision [ 41 ]. The best way to ensure that
decisions are not arbitrary or capricious is to use a competency or progress commit-
tee. A large percentage of deficiencies only become apparent when the faculty meet
to discuss performance because this allows patterns of behavior to become apparent
and provides evidence that strengthens individuals’ preexisting convictions about
performance deficiencies leading to a corporate judgment that is more stringent than
that of individual raters [ 42 , 43 ]. The minutes of this meeting will provide more
robust documentation than that of the individual attending. Another consideration is
that faculty members with only occasional contact with residents tend to be more
generous with their ratings; thus, these ratings need to be interpreted with caution.
Narratives are often more useful than numeric ratings in identifying issues. The best
way to ensure that decisions are not arbitrary or capricious is to use a clinical com-
petency committee. Problems are often identified in committee discussions that are
not raised by individuals permitting the identification of patterns of behavior when
an individual saw only a single instance [ 42 – 44 ]. Such committees serve as checks
and balances, particularly in identifying the marginal resident.
Conclusion
The guiding principles for addressing unprofessional behavior include setting
very clear expectations as to what is meant by professional behavior, modeling
such behavior, and holding others accountable. All complaints should be taken
seriously and fully investigated to get both sides of the story. Program directors
should incorporate an assessment of trustworthiness and ability to take responsi-
bility for personal behavior into resident evaluations and note system problems
that enable unprofessional behavior by providing secondary gain for such16 Promoting Professionalism