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You are a role model

From the October ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Stacey Butterfield

Turfing, blocking, making fun of the emergency department—every hospitalist knows that these behaviors aren't indicative of professionalism. Yet most hospitalists have witnessed them, and some may have participated themselves.

And when academic hospitalists observe their peers behaving unprofessionally, chances are residents and students are seeing the same thing. It was this risk of negative role-modeling that led Vineet M. Arora, MD, FACP, and colleagues to recently attempt to quantify the incidence of unprofessional behavior among hospitalists. They asked 100 hospitalists at three academic medical centers to review a list of behaviors and report how unprofessional they believed each behavior to be and whether they ever participated in or observed it.

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Courtesy of Dr. Arora.

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The findings were mostly reassuring (for example, fewer than 3% of hospitalists report ever having discharged a patient early to reduce workload) but did provide some useful lessons for physicians and educators concerned about professionalism, according to Dr. Arora, who is associate professor of medicine and associate program director of the internal medicine residency program at the University of Chicago.

She spoke with ACP Hospitalist about her findings, which were published online by the Journal of Hospital Medicine in May.

Q: What led you to study this subject?

A: We started studying student and resident professionalism because there's such a focus on making sure trainees are acting in a professional manner. Residents and students told us we really needed to look at attendings. Hospitalists seemed like a natural group to study because they are on inpatient medicine a lot. Since professionalism is a core competency of hospital medicine, we thought this might be a good time to see what hospitalists think about these behaviors.

Q: How did your results compare to your expectations?

A: Overall, the participation in the [unprofessional] behaviors was extremely low, especially related to training and trainees. Nearly all hospitalists we studied recognized that making trainees do [inappropriate] things or mistreating trainees is grossly unprofessional, and we had almost zero participation in those behaviors, which we were really reassured by. Also rates of egregious behaviors like falsifying notes and records were also very low. That has been consistent with all of our prior studies, which show that the egregious behaviors are not actually very common.

Q: What about less egregiously unprofessional behavior?

A: A lot of media have fixated on [the finding that 67% of hospitalists reported talking in the hallway]. We ask about a range of unprofessional behaviors, to avoid having the entire survey focus on egregious behaviors and so we can make comparisons. You can gauge how unprofessional misrepresenting a test as urgent or disparaging a patient is compared to having a personal conversation in the hallway. Hospitalists did note that the most egregious behaviors were unprofessional, and the less egregious behaviors were less unprofessional. Interestingly, hospitalists reported staying past shift limit to do work was actually professional, which is very important in the setting of duty hours. If the attending role models believe staying past shift limit is a typical and professional activity, it's going to be difficult to enforce resident duty hours.

Q: What other findings were surprising?

A: Probably the most interesting was that certain hospitalist job characteristics predicted behaviors. For example, many people think that the more clinical work you do, the more burned out you are, and maybe that would lead you to behave unprofessionally. Certainly, that's what we see in residents—the more clinical work they face, the more burned out they get, the more unprofessional they are. But in hospitalists, the folks who did more clinical work were less likely to make fun of others—make fun of patients, make fun of residents, make fun of other doctors, make fun of other staff. Hospitalists that do a lot of clinical work probably value their relationships in the workplace and have a better sense of what's professional and what's not. In fact, it might be that attendings who do less clinical work are more easily influenced by their residents and others to participate in certain behaviors.

Q: What findings from the survey were most concerning?

A: Things like blocking an admission, celebrating a blocked admission, turfing—these behaviors do happen in the workplace, primarily because workloads may be very high. More people admit to celebrating these things than actually doing them, but while people didn't report participating in these behaviors, they did report observing them, so they are happening in the workplace. Those behaviors are concerning because they certainly could impact patient care. You could imagine a case where people spend more time engaging in a dialogue about where the patient could go rather than taking care of the patient. Those are concerning behaviors and those are behaviors that we actually have been trying to target through our intervention.

Q: What's your intervention?

A: We have funding from the American Board of Internal Medicine Foundation to do a series of video-based education with hospitalists. We've created videos to target certain behaviors. One behavior that stood out was disparaging the emergency department or primary care physicians for missed findings that were discovered on the floor. That was concerning because we want to make sure that hospitalists have a good understanding of the nuances of what it's like to see patients in these different settings. We're working with the ABIM Foundation to disseminate these videos.

Q: What lessons can hospitalists take from your findings?

A: We don't want to sound very preachy. We don't want to indict our field. Again, the egregious behaviors were very low, which was reassuring. However, some of the behaviors that we're describing are really prevalent. Hospitalists are role models. By empowering hospitalists to recognize these behaviors as unprofessional, our videos have at least shown preliminarily that people can change their perception. This is the first step. Our studies have always shown the more unprofessional you think the behavior is, the less likely you are to participate.

Q: What lessons does this study offer hospitalist leaders?

A: If you're a hospitalist director, it may be that you want to focus on the hospitalists that don't have a lot of teaching work with the residents and do some faculty development with them to make sure they understand the importance of being a professional role model. Talk with hospitalists who have different jobs about the types of unprofessional cues they may face in the workplace or the types of stresses they may be put under, so that they can recognize when and how to behave professionally.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated