Professionalism Policy

UGME Student Professionalism Policy (Policy # SC-02)
Approved by SOME on November, 16, 2010
Lead Writer: M. Reesor, UGME Program Manager
Last Revised: November 22, 2010 with changes approved by SOME Chair

1.0 Preamble

The process of transitioning from a student to a medical professional is a complex and lengthy one which requires self-reflection and study on the part of learners. In order to make the transition as seamless as possible, students benefit from explicit instruction within the curriculum. [1]  

The code of professional behaviour for a physician extends beyond regular working hours into almost all aspects of life. However, for most students this reality is not apparent at the outset of their medical education. Data suggest that medical school applicants approach the admission process well versed in academic and non-academic requirements (e.g. service, volunteer activities) but with very little knowledge of what it means to be a physician in terms of professional values and conduct. [2] Furthermore, many students view the integration of some core professional values (e.g. altruism) into their lives as problematic. [3]

The College of Physicians and Surgeons of Ontario is clear about the expectations of the medical profession for its members:

“Medical professionalism is the translation of the values of the profession — compassion, service, altruism, and trustworthiness — into action. Medical professionalism is demonstrated when these values are upheld in the everyday interactions that comprise each doctor’s own medical practice. Professionalism also underpins the social contract between the medical profession and the public: in return for a monopoly over the practice of medicine, professional autonomy and the privilege of self-regulation, the profession has made a commitment to competence, integrity, altruism, and the promotion of the public good within its domain. This social contract is reflected in the ethical tenets of the profession, the legislation governing the profession, and the standards of practice for physicians.” [4]

Queen’s University School of Medicine needs to be similarly clear in order to adequately equip students for the profession they are entering. Therefore, students are expected to exhibit professional values at all times starting with their first day as medical students. This is achieved through the designation of professionalism as a core competency within the undergraduate curriculum and through role modeling of senior students, residents, and physicians. The aim is to admit students already exhibiting the basic values of a medical professional; it is expected that these basic values will form a solid foundation upon which a deeper understanding of medical professionalism can be built and applied to a lifetime of education and practice.

Learning objectives vis à vis professionalism include:

P1.1 Professional Behaviour

The competent medical graduate: Practice appropriate professional behaviours, including honesty, integrity, commitment, dependability, compassion, respect, an understanding of the human condition, and altruism in the educational and clinical settings. The graduate is able to:

a. define the concepts of honesty, integrity, commitment, dependability, compassion, respect, confidentiality and altruism as applied to medical practice and correctly identifies examples of appropriate and inappropriate application

b. apply these concepts in medical and professional encounters

P1.2 Patient-Centered Care

The competent medical graduate: Delivers highest quality patient-centered care, with commitment to patients’ well being. The graduate is able to:

a. Define the concept of “standard of care”

b. Apply diagnostic and therapeutic modalities in evidence based and patient centred contexts

P1.3 Self-Awareness

The competent medical graduate: Is self-aware, engages consultancy appropriately and maintains competence The graduate is able to:

a. Recognize and acknowledge limits of personal competence

b. Acquire specific knowledge appropriately to assist clinical management

c. Engage colleagues and other health professionals appropriately

P2.1 Ethics

The competent medical graduate: Analyze and appropriately respond to ethical issues encountered in practice (such as informed consent, confidentiality, truth telling, vulnerable populations, etc.) The graduate is able to:

a. Analyze ethical issues encountered in practice (such as informed consent, confidentiality, truth telling, vulnerable populations etc)

b. Analyze legal issues encountered in practice (such as conflict of interest, patient rights and privacy, disclosure of medical error etc.)

c. Analyze the psycho-social, cultural and religious issues that could affect patient management

d. Define and implement principles of appropriate relationships with patients

P2.2 Law and Regulation

The competent medical graduate: Apply profession-led regulation to serve patients, the profession and society. The graduate is able to:

a. Recognize the professional, legal and ethical codes and obligations required of current practice in a variety of settings, including hospitals, private practice and health care institutions, etc.

b. Recognize and respond appropriately to unprofessional behaviour in colleagues [5]

 

1.1    Statement of Purpose

Delineating expectations around professionalism and role modeling such behaviour for students are important to student learning. However, this “must be combined with reflection on the action to truly teach professionalism… Medical educators must set expectations, create appropriate learning experiences, and evaluate outcomes. Educators must be clear about professional expectations — both the rationale behind them and the consequences of failing to meet them.” [6]

The objectives of this policy are:

1. to demonstrate the priority placed by the School on professional behaviour
2. to identify lapses in professional behaviour as early as possible and provide appropriate remediation
3. to identify exemplary professional behaviour so that it a) may be recognized and b) be used a potential vehicle for peer-modeling
4. to provide students, faculty and staff with a clear articulation of expectations vis a vis student professionalism
5. to provide the School with clearly articulated authority to act when dealing with professionalism lapses
6. to identify procedures for managing student professionalism issues
7. to provide a longitudinal approach (i.e. not course-by-course or year-by-year) to monitoring students’ behaviour

1.2    Rationale

The Queen’s University School of Medicine has an obligation to patients, students, the healthcare community and, society at large to educate students on their professional obligations. In fulfilling this mandate, procedures must be in place to recognize exemplary examples of student professional behaviour. Similarly, when students fall short of professional behaviour expectations, the School must make them aware of improper conduct and undertake necessary remediation in order to ensure that negative patterns of behaviour are replaced by positive ones.  

Furthermore, professionalism scholarship clearly signals that professionalism must be taught if medical educators are to fulfill their obligations to students, patients, the profession and society. [7]

As such, the School of Medicine must provide normative and summative feedback to students regarding their professional behaviour not just in discrete courses which explicitly teach professionalism but in all education contexts.

1.3    Scope

This policy applies to the following learning contexts:

1.      all classroom-based milieu (e.g. lab, lecture hall, exam hall etc.)

2.      all clinical settings that are part of the learning program (e.g. hospitals, clinics, community health centres, ambulatory settings, etc.)

3.      other milieu that are not part of the formal learning program but contribute to the learning process. Examples include: student-run special interest group meetings and activities, clubs and governance structures; interactions with University administrators and other members of the campus community; University-supported events

1.4    Definitions

A profession is defined as follows:

“An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.” [8]

Lapses in professional behaviour will be evaluated as minor, major, or critical and be defined as follows:

Minor lapses – These are errors that have minimal consequences. Often there is no awareness of the unprofessional act or, it occurs after the fact. There may often be mitigating circumstances.

Examples:

a)     Student falls asleep on stretcher in the hall of the hospital

b)      Student does not meet deadline for paper due to family illness but fails to notify anyone

c)      Student disparages a proctor after an exam for asking them to stop writing at the end of the designated time period

Major lapses – Major lapses are errors that have potentially serious consequences. Often there is awareness of the unprofessional act. Usually, there are no mitigating circumstances

Examples:

a)     Student refuses to return phone calls and e-mails from a professor

b)      Student does not answer his/her pager from the emergency room

c)      Student rushes in to see a patient with “interesting” findings despite being told not to do so

d)     Student posts patient information on a social networking website without adequately taking measures to protect the patient’s anonymity

Critical Lapses – Critical lapses have direct harmful consequences or are clear breaches of well recognized standards.   They are serious errors that will require immediate action by a supervisor. They are a clear violation of the professional code of conduct.

Examples:

a)     Student being dishonest either by lying or misrepresenting himself/herself including instances of academic dishonesty

b)      Student hitting a patient

c)      Student being sexually inappropriate with a patient or fellow member of the health care team.

e)      Student interviewer breaching confidentiality of admission interview questions by forward feeding questions to a candidate(s) that will be interviewing the following weekend

Examples of exemplary professional behaviour will be defined as follows:

Situations in which a student exhibits an exceptional commitment to the principles of medical professionalism that is recognized by peers, patients, instructors, healthcare team members or members of the wider University community.

Examples:

a) student alerts instructor to a calculation error during an exam viewing that has incorrectly inflated their score by 10%

b) student interacts with an angry patient dissatisfied with their care in a respectful manner that diffuses the situation

c) student creates local volunteer organization in which Queen’s Medical students provide teen health advocacy programs for residents of North Kingston.  

1.5    Evaluation

In evaluating outcomes, the goal is to “reward the best professional behavior, enhance professionalism in all students, identify the few students who show deficiencies in professionalism, and dismiss the rare student who cannot practice professional medicine.” [9] This will be achieved by:

·        Ensuring all students are familiar with the objectives of the professionalism competency and require them to adhere to its principles.

·        Ensuring all students are aware that exemplary behaviour will be recognized and that lapses, depending on the level of severity, will be met with varying degrees of sanction.  

·        Ensuring all staff, faculty, preceptors, residents, etc. working with students are familiar with the objectives of the professionalism competency and directing them to note any behaviour that they view as either exemplary or contrary to its principles.

·        Documenting all professionalism incidents and determining appropriate consequences

1.6    Governance

Incidents of student professional conduct or misconduct will be reviewed by the Professionalism Advisory Committee (PAC) whose membership will be comprised as follows:

·      Four members of the Faculty, three of whom will hold the rank of Associate Professor or Professor . Three will be from clinical departments and one from a basic science department.

·    One member will hold the rank of Associate Professor or Professor at another Queen’s University Professional School.

·    One member will be a current medical student and hold an executive position in the Aesculapian Society.

·    One member will be the UGME Program Manager.

·    The Director of Student Affairs shall sit on the Committee as a non-voting member specifically to represent the interests of students known to their Office.

PAC will normally meet monthly during the academic year with extraordinary sessions called to address significant professionalism issues.

1.7    Procedures

Exemplary Behaviour

1)      Incidents of exemplary student professional behaviour should be submitted in writing to the UGME Program Manager. Submissions should include:

-        the name of the person involved

-        the name and title of the individual filing the report

-        the time and location of the incident

-        details outlining why the behaviour can be constituted as exemplary

-        the name(s) and contact information of a reference with first-hand knowledge of the achievement

2)      The UGME Program Manager will review the submission and document using the Incident Report housed on MEdTech (see Appendix 1). A paper copy of the report will be placed in the student file.

3)      The UGME Program Manager will communicate details of the incident at the next PAC meeting.

Lapses

1)      Lapse is identified by instructor, supervisor, course director, staff member or peer.

2)      Written summary of lapse is communicated to UGME Program Manager. Student is advised that the incident has been noted and will be reviewed at PAC meeting. (Note: In cases where the lapse is deemed to be potentially classified as critical an extraordinary meeting of PAC may be called in order to have the case reviewed more quickly.)

3)      UGME Program Manager files incident report and adds to agenda for next PAC meeting. Copy sent to student.

4)      PAC reviews incident and classifies lapse as minor, major or critical. PAC also determines appropriate consequences and remediation plan.

5)      Student is notified in writing of PAC’s decision. All major and critical lapses will also be communicated to the UGME Associate Dean and Faculty of Health Sciences Dean.

6)      Student may appeal decision. If so, their intent to do so should be filed in writing within 5 business days of receiving the PAC decision. An appeal hearing will be scheduled to take place within 10 business days. Upon hearing an appeal PAC may decide to change the classification of the lapse and/or the nature of the consequences and remediation plan.

7)      If the original PAC decision is not changed upon appeal, a student has the right to appeal to the Faculty of Health Sciences Student Appeal Board.

 

1.8 Consequences

Exemplary behaviour may be noted in the MSPR and/or at the graduation ceremony.

Professionalism lapses are viewed first and foremost as an opportunity for education and remediation. The intent is to provide opportunities for students to become conscious of their professional obligations and learn how to alter their behaviour accordingly. Whenever possible, consequences should reflect this belief.

Consequences will vary in severity based on the following factors:

- classification of the lapse

- whether the student has had previous lapses

- the level of responsibility shown by the student

- extenuating circumstances

Consequences may include though not be limited to:

-        Research and reflection resulting in a written submission

-        Issuance of apology

-        Counseling

-        mandated meetings with a mentor

-        academic penalty

-        notation in MSPR

-        repetition of a course, term, clerkship rotation or year

-        suspension or expulsion from Queen’s Medical School

Appendix 1