Quality in Primary Care Open Access

Keywords

Speaking up behavior; Professionalism lapses; Unprofessional behavior; Medical education

Introduction

In a previous study (currently under review), the authors explored the motivation of medical students to respond—or not respond—to unprofessional behaviors they encounter in medical school. Based on this work, a workshop was developed for undergraduate students, in which they learn how to speak up about unprofessional behavior of supervisors and peers. In this workshop, students can role-play difficult conversations with the help of actors, so-called ‘simulated patients’. As the patient perspective on speaking up behavior is important and currently missing in the literature, this perspective article will present the experiences of two simulated patients, Michel Stoeltie and Jorick Jochims. They enact patients, supervisors and peers in training sessions for medical students. The perspectives of these simulated patients could illustrate the issues encountered and help educators to improve the teaching of professionalism.

Background from the Literature

Unprofessional behavior of physicians can put patient safety at risk. Recently, this was illustrated by Cooper et al. [1] who reported that unsolicited patient commentaries about unprofessional behaviors of a surgeon (e.g. relating to disrespectful communication or poor availability to patients) are associated with post-operative complications. This research once more highlights that any physician should be willing and able to respond to lapses of professionalism of colleagues [2]. Unfortunately, speaking up is not always easy. For medical students, who are still learning and dependent on their teachers for grades, it is even more difficult. Professionalism lapses, either from students or faculty, are sometimes serious, such as falsifying medical records or sexual harassment, but more often they are less extreme, such as poor engagement, disrespectful communication or poor insight into own behavior [2-5]. Displaying a professionalism lapse does not automatically imply that an individual is an ‘unprofessional’ person: many professionalism lapses result from inadequately handling interpersonal and system factors in the workplace, to which all physicians are susceptible [6]. However, even mild lapses can have adverse effects on patients [1].

Medical students overwhelmingly endorse an obligation to respond to professionalism lapses [7], but they experience difficulties in honouring this obligation [8]. Students often decide to avoid responding to a morally troubling situation, since they experience difficulties in challenging an individual. These difficulties can be personal constraints, e.g. a lack of confidence in own knowledge and judgment, and/or systemic constraints, e.g. repercussions for grades or opportunities, fear of damaging relations, and hierarchy [9,10]. Thus, addressing both personal and systemic constraints is crucial to make students respond to observed unprofessional behavior.

Acknowledging the relevance of unprofessional behaviors for patient safety, physicians should respond to such behaviors and openly discuss them. An important development in medical practice is the acknowledgement that effectively handling such lapses requires peer support among physicians [11,12]. Medical educators can teach their students how to support each other, and influence system factors if possible. The goal would be to learn from lapses lapses, individually and collectively, and ultimately influence personal, interpersonal and system factors to prevent future professionalism lapses [2,6].

What we did

In 2015, consequently the workshop 'Responding to unprofessional behavior of faculty and peers' was developed for undergraduate medical students, as part of a communication programme that promotes healthcare communication between patients and healthcare practitioners [13]. The underlying principle of this workshop is that students learn to discuss the unprofessional behavior in such a way that it is ‘tough for the case, gentle for the person’.

In each session, a group of twelve students is guided by a teacher who is assisted by a simulated patient participating in role plays. Students are asked to present a situation in which they observed unprofessional behavior, be it displayed by a person in their private life, a peer student, or a supervisor in the medical school. Students are invited to initially role play the way they addressed the troubling situation as it had occurred, discuss among each other alternative options to respond, and subsequently try out these alternatives in further role plays.

Simulated Patient’s Perspective

Simulated patients Michel Stoeltie and Jorick Jochims regularly participate in the workshop ‘Responding to unprofessional behavior of faculty and peers’. Both are educated as actors, and have been working as simulated patients in medical education for more than ten years. Currently, both contribute to more than 100 sessions of 20 different workshops a year, for undergraduate, graduate and postgraduate medical students. An important reason for them to work as a simulated patient is the wish to advance communication in health care, not only between physicians and patients, but also between physicians themselves.

As patients, both Michel and Jorick advocate that future physicians practice the skills of responding to unprofessional behavior. Both indicate that they expect physicians not only to behave professionally themselves, but also to take responsibility for the professionalism of the group of physicians as a whole. This means that they expect their physician to speak up when observing unprofessional behavior of a colleague. Michel states: “Patient safety can be threatened if miscommunication takes place. Physicians should respond to unprofessional behaviors in the workplace, but I don’t think they adequately do that.”

As simulated patients in the workshops, Michel and Jorick recognize the constraints that students encounter in responding to unprofessional behaviors and understand that these constraints can result in avoiding to respond. Michel: “I see that for students ‘avoiding’ is very common, even if the situation is clearly morally unacceptable”. Jorick explains: “Maybe, it seems that ‘avoiding’ might be a good option in the short term, but it will not create change, and thus is a bad option in the long term.” Thus, the teaching and practicing of personal skills to respond to adverse situations is deemed very necessary. Michel declares: “Students who take the opportunity to practice can learn a lot in this workshop” and as Jorick expresses it: “Training the responding muscles is key!”

Both simulated patients experience that students, when role-playing their response, often feel that they address the issue too strongly, and express themselves rudely or even abusively. At the same time the simulated patients feel that students downplay the issue, resulting in an ineffective delivery of the intended message. Michel: “Students are so glad that they finally address the issue that they understate their message, which is thus not adequately understood by the addressed person. I see that students tend to be happy with any solution that can be reached, even if this does not solve the initial problem at all.” They see that students pay a lot of attention to the relationship, which undermines the content of the case itself.

Both simulated patients indicate that they have experienced that the guiding principle of the workshop, ‘be tough for the case, gentle for the person’, is very helpful for students. They state that, if students succeed in making a distinction between the way the case is discussed and the way the person is treated, they will be able to bring the intended message across clearly, without offending the person addressed.

The two simulated patients state that not only students, but also all teachers (both non-clinical teachers and clinician-educators) of the medical school have to behave professionally. They prefer that all teachers are also trained in responding to unprofessional behavior; teachers need not only to learn how to respond, but also to learn how be open to feedback themselves. Michel: “Do the teachers know how much time and effort is paid to teach students how to respond to unprofessional behaviors?

Maybe teachers themselves could benefit from the same sort of trainings, in which we as training-actors could enact the students”. Teachers are important role models. They can create a safe learning environment by showing their students that it is normal to give and receive feedback, even about the difficult topic of unprofessional behavior. Jorick: “Addressing unprofessional behavior is often seen as a punishment, while the intention should be to help your colleague to improve their behavior.” By role modelling to their students an open, supportive way of responding, teachers can help to create a culture in which it is accepted to address behaviors among each other. The simulated patients acknowledge that such a culture change may take decades to accomplish, and that therefore, medical educators better start initiating this change now.

What to do next?

Every medical professional should be willing and able to have a constructive conversation about professionalism [2]. This is crucial to ensure high quality patient care [1]. An important development for medical practice is the acknowledgement that effectively dealing with professionalism lapses requires peer support among physicians [11,12]. Acknowledging the importance of peer support has implications for the teaching of professionalism, including the responding to unprofessionalism, in medical schools.

Medical schools must teach their students how to speak up about professionalism lapses that they encounter. Some medical schools already pay attention to this topic, by supporting students to overcome personal constraints that hamper them to respond to unprofessional behavior. An example is a UK medical school that developed a structure for student-led interventions to encourage students to respond to lapses. Students are taught how to initiate conversations about concerns in a nonthreatening way, strengthening students’ confidence to respond [14]. However, educators also have to pay attention to the systemic constraints, and ensure that the learning environment is safe enough for students to administer the acquired skills. Recently, Martinez introduced a survey scale to measure the support that residents receive from the clinical environment to speak up. This scale could possibly also be generalised to other contexts to discover the system factors that support or hamper responding to unprofessional behavior [15].

Conclusion

At VUmc School of Medical Sciences a workshop has been running for two years for undergraduate students to improve their skills to respond to unprofessional behavior in the workplace. Simulated patients participating in this workshop feel highly involved in reaching this goal. Their opinions explicitly support the assumptions that are made in the medical education literature about this topic: all involved in health care—students, educators, physicians and patients—have a responsibility to change the atmosphere in medicine towards an open supportive culture in which it is acknowledged that lapses in professionalism can occur in people with good intentions [2,6]. By openly discussing such lapses, in a way that is ‘tough for the case, gentle for the person’ we can put a step towards changing the culture in health care.

References

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