There are several problems and issues related to medical professionalism among medical students, especially the allopathic and osteopathic medical students all over the world and the United States in particular.
Some of the problems faced by the medical students are; Practicing medicine while under the influence of alcohol, narcotic or hypnotic drugs or any substance that impairs or may impair the licensee’s ability to safely and skillfully practice medicine and many more. Most of the solutions adopted by these institutions are based on several studies that they have either commissioned or just done by individuals. The solutions range from policy guidelines, proper curriculum and taking disciplinary actions where the situation is not bearable.
Robert F. Sabalis gave a keynote Address in 2002 at the National Association of Advisors for the Health Professions (NAAHP). In his keynote, he stated that “health professionals, once licensed, enjoy one of the best seats in the house to observe the human condition. They hear patients’ secrets. They prescribe toxic substances. They undress and touch people. They remove bodily organs. They relate to people in their most vulnerable moments. They participate at the beginning and the end of life. They discuss matters of life and death. They do all of this in exchange for significant autonomy and financial support for their education, research, clinical activities, and for the promise to practice in accord with professional codes”. He clearly indicated the value appended to health professionals in society, hence the need for them to practice professionalism to the best of their ability.
There are growing problems and issues related to medical professionalism among medical students, especially the allopathic and osteopathic medical students both in the United States and outside.
Some of the problems faced by the medical students are; intentionally betraying a professional secret or violating a privileged communication except as either of these may otherwise be required by law, committing a felony, whether or not involving moral turpitude, or a misdemeanor involving moral turpitude, Practicing medicine while under the influence of alcohol, narcotic or hypnotic drugs or any substance that impairs or may impair the licensee’s ability to safely and skillfully practice medicine, excessively or illegally use of alcohol or a controlled substance, Prescribing, dispensing or administering controlled substances or prescription-only drugs for other than accepted therapeutic purposes and engaging in the practice of medicine in a manner that harms or may harm a patient or that the board determines falls below the community standard. Other unprofessional conducts are; impersonating another physician, acting or assuming to act as a member of the board if this is not true, procuring, renewing or attempting to procure or renew a license to practice osteopathic medicine by fraud or misrepresentation, having professional connection with or lending one’s name to an illegal practitioner of osteopathic medicine or any of the other healing arts, representing that a manifestly incurable disease, injury, ailment or infirmity can be permanently cured or that a curable disease, injury, ailment or infirmity can be cured within a stated time, if this is not true, failing to reasonably disclose and inform the patient or the patient’s representative of the method, device or instrumentality the licensee uses to treat the patient’s disease, injury, ailment or infirmity, refusing to divulge to the board on demand the means, method, device or instrumentality used in the treatment of a disease, injury, ailment or infirmity, charging a fee for services not rendered or dividing a professional fee for patient referrals, violating or attempting to violate, directly or indirectly, or assisting in or abetting the violation of or conspiring to violate any of the provisions of this chapter, failing or refusing to establish and maintain adequate records on a patient as follows, using controlled substances or prescription-only drugs unless they are provided by a medical practitioner, as defined in section 32-1901, as part of a lawful course of treatment, prescribing controlled substances to members of one’s immediate family unless there is no other physician available within fifty miles to treat a member of the family and an emergency exists, nontherapeutic use of injectable amphetamines, violating a formal order, probation or a stipulation issued by the board under this chapter, harging or collecting an inappropriate fee. This paragraph does not apply to a fee that is fixed in a written contract between the physician and the patient and entered into before treatment begins and much other misconduct.
These “unprofessional conducts” have been observed to grow considerably at an alarming rate. They range from practicing medicine under the influence of substances that may interfere or impair the brain’s ability to function thus the inability of the licensee to execute his or her duty in a skillful and professional manner. However, medical schools, residency programs, and hospitals have been making several efforts to find a solution to such unprofessional conduct either through their regulatory body or as individual health facility.
A study conducted by the School of Medicine, University of Missouri, Columbia found out that the “most common reason that women give for not undergoing screening for breast cancer and cervical cancer is that it was not offered or recommended by their physicians, especially by the youngest group of internists and family practitioners” (Lurie et al 329). This is a typical case of a medical intern ignoring the responsibility of proper diagnosis; hence failing to understand the level of trust put on them by the patients as regards the diagnosis process, outcome and their subsequent advice.
Some medical interns have also been found to charge fees for some services that are not rendered or overcharging the patients, or even dividing a professional fee for patient referrals, an act meant to derive material benefit dishonestly from the patients. A research done by Richard Kronick, PhD, entitled “Medicare and HMOs- the Search for Accountability”, he found out that the “Medicare Payment Advisory Board (MedPAC 201) has estimated that the overpayment is 14% in 2008”. This was calculated to be around $10 billion. He however did not entirely agree with this figure and concluded that the figure is obviously bigger “since this estimate does not take into account health plans’ successful efforts to raise their risk-adjusted payment amount by increasing the number and severity of the diagnosis that they report”.
In an attempt to handle such complexities in the charging of fees by medical centers, the Centers for Medical Services “began the process of reducing payments to Medicare Advantage plans. That rates for 2010 will average 4.0 to 4.5% lower, in nominal dollars, than rates for 2009, reflecting a 3.4% adjustment for diagnostic coding intensity, an assumption that fee-for-service Medicare expenditure will increase by only 0.8% from 2009 to 2010, and other technical adjustments in the rate-setting process” (CMS 2009). It has been noted that the level of accountability among the Medicare students is almost difficult to measure hence the intervention by the CMS. The government’s inability to monitor numerous hospitals and physicians has become the focus since the resources required would be enormous. This clearly indicates that it is not easy to monitor the hundreds of thousands of Medicare students. CMS has therefore planned to reward the best practicing physicians and interns in order to encourage them to work hard towards accomplishing professional ethics.
In an effort to improve the services of the interns, many hospitals have decided to use scorecards so as to improve the services rendered to the patients. Specific scorecards are being applied to specific interns in order to monitor their performance and professional conduct. One such method has been successfully applied by hospitals in New York. “in-hospital and 30-day risk-adjustment mortality rates following by-pass surgery were significantly lower in regions with public dissemination programs than in the remainder of the United State” (Hannan et al 69). However, a survey conducted among the cardiac surgeons who were exposed to scorecard evaluation in New York in 1997, “67% of the respondents indicated that they had refused to offer bypass surgery to at least one patient within the previous year”, ostensibly to avoid being accused of professional misconduct. This indicated that senior professionals Medicare professionals would avoid everything not to be monitored and blamed for not working professionally. But this was well applied to the interns who had no options but to get oriented to the field of medicine (Hauer et al 16-20).
Medical interns have also been diagnosed with illegally using excessive alcoholic or controlled substances when carrying out a professional duty or just illegally using alcohol when conducting professional duty. One of the institutions that have been established to handle serious cases of mental problems among medical students is the Dakota Counseling Institute. They train Interns in clinical and counseling psychology, where Medicare graduate students and interns are exposed to practicum training, where the main goal of this training is to help the Medicare students learn the independent professional practice. Some of the key areas that the programs offer are; training on Medicare professionalism, Medicare ethics, and legal issues in Clinical Practice. They are also taught how to conduct professional consultation (Hannan et al 35)
Before any admission to a medical school, residency programs, or hospitals, other than technical knowledge and good scores in GPA, these institutions also look at the professional ability of the applicants. They look at the desired attribute before admission that would enhance the professional ethics when practicing. The admission officers, therefore, evaluate the applicants to these programs so as to come up with those who have the best attributes in terms of technical, good grades and ability to practice professionalism (Hauer et al 25- 30).
In Medicare professional practice, studies conducted by Kathleen et al on physicians and trainees, “communicating with the patient about medical error”, trainees responded when asked how they committed some of the worst medical errors, that most of them had neither discussed the problems with the family members nor the patient. “Only 24% of the trainees had discussed the error with patient or family” (Miller, et al 43-49), with most trainees citing the fear of litigation that may make them hold back any information on any form of error especially those ones that are avoidable. But further research was done by Irby and Milam that “when due process is followed, program directors can expect the courts to appreciate the importance of upholding professional and academic standards”. However, most hospitals make sure that every intern or trainee in the medical field is accompanied by a senior medical practitioner and when doing the diagnosis. This has been designed such that when the diagnosis is conducted, the senior physician is responsible (Tervo 161).
Many health institutions have also involved researchers in the studies to determine the best ways to solve the problem of unprofessionalism among young medical professionals. For example, Karen E. Adams conducted research on “How resident behavior is identified and managed. She found out that many program directors were willing to discuss the “unprofessional misconduct” with interns as they are hired. She also found out that poor record-keeping or documentation leads to delay in problem-solution efforts. “despite many efforts put on the large programs, the solution lies in somehow little programs that would ensure that the trainee practitioner admits their unprofessional conducts and ask for the opportunity to correct their mistakes”. And that it is important to acknowledge that interns or trainees will at appoint display some unprofessional conduct in the process of carrying out their duties and responsibilities. “That the students, residents, faculty, and administrators should work together to create an institutional culture in which reflection, acknowledgment of mistakes and recommitment to the highest standards of professionalism” is observed so as to give victims an opportunity to recollect themselves. This kind of approach has been applied by many healthcare institutions’ proven success since most senior practitioners will acknowledge that as the new interns are inducted into the field of Medicare, they are likely to be exposed to challenging elements of practice. They advise that professionalism should be observed as a “progress in learning”, hence the acceptance of lapse and “recommitment to the highest standards” is necessary. That “stringent performance standards….and dismissal” are not the best alternatives unless it is the extreme end of unprofessionalism (Hannan et al 39)
Medical schools also have policies that guide the actions taken against “struggling medical students”. Those are students who get lower grades or below pass marks simply because of their basic skills and knowledge of medicine or just professionalism. In a research conducted by Frellsen et al, published by the Pub Med, “two-thirds of respondents present struggling student to a medical school promotion committee”, that more than a half of the students (respondents) were willing to divulge information with the directors of internship and that half of the students actually do share the information of their inability to cope or their overindulgence in alcoholism or drug consumption. However, 57% of internship directors have designed “remedial plans” to help struggling students against 14 % and only number of institutions’ directors who have written policies as regards the struggling student.
The University of California, through Hauer K. (PhD) conducted a study on “students’ performance in medical school clinical skills assessment skills. The results were just as similar to other results conducted by various institutions. The study was administered to find out students who have not achieved “competence, the types of problems uncovered that they may have been facing in the course of their study period. The findings were ranging from deficiency in “interpersonal skills” to lack of “insight”. That poor performance in overall practice is attributed to “cognitive ability” deficiency and inability to communicate effectively. They recommended that the most appropriate remedy for such cases is to do early identification and carry out an appropriate intervention. (Lurie N, 481-486)
The use of internal exams has been applied by the medical directors to analyze the medical student’s performance. A study conducted in 1999 by Internal Medicine Directors of Clerkship in over 120 institutions found out that most National Board of Medical Examiners used subject examination (83%). However, those who used a combination of “standardized patient exam” and subject examination was about 80%. In what seems to be unanimous criteria, only 25% of the final grading came from exams. Those students who fail to pass their exams but have very good scores or performance in clerkship are allowed to re-sit the exam test after “self-study”. If they fail again in the re-test, they are classified as unqualified and are recommended to acquire additional medical experience before they are accepted back. Of all the Clerkship directors who reportedly used the “National Board of Medical Examiners subject examination, 50% gave recommendations on how to improve the examination process. Suggesting the improvement on contents of the examination, reporting of the results, basing the results on “published core curriculum, and the use of other general issues related to administration. The findings further showed that in the past ten years, the use of Board’s examination has tremendously increased to 83% from 66%, while the use of “faculty- developed examination” has declined from 46% to 27%. On the other hand, the use of clerkship standardized patient examination shot up from mere 2% to 27%. This clearly illustrates how different institutions’ Directors have adopted a positive trend toward applying the competency test through the use of “standardized patient examination” (Lurie N, 460)
At the same time, there is a general trend in the use of “Objective Structured Clinical Examination” (OSCE) by the Medical institutions or bodies, that according to a study conducted by Trevo RC et al, is “well established, with an extensive body of research documenting that is a valid means to assess clinical skills that are fundamental to the practice of medicine.” Such institutions that have applied them are like Unversity of South Dakota, School of Medicine. The system is consisting of a range of tests exams that are inclined toward testing the undergraduate fundamental skills of medicine, student’s performance and arranges of other tests like communication skills and public relations skills. Other than these skills, the OSCE is able to classify areas that are necessary to be improved for the effective running of the curriculum.
Lurie N, 1993. Preventive care for women: does the sex of the physician matter? N Engl J Med; 329: 478-482.
Advance notice of methodological changes for calendar year (CY) 2010 for Medicare Advantage (MA) capitation rates and Part C and Part D payment policies. Baltimore: Centers for Medicare & Medicaid Services.
Announcement of calendar year (CY) 2010 Medicare Advantage capitation rates and Medicare Advantage and Part D payment policies, Baltimore: Centers for Medicare & Medicaid Services.
Palliative Care at the End of Life – Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians, Baltimore: Centers for Medicare & Medicaid Services.
Dementia – Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians Screening Mammography – Screening Mammography for Women 40 to 49 Years of Age: A Clinical Practice Guideline from the American College of Physicians
J Am Podiatr Med Assoc, 2007. How resident unprofessional behavior is identified and managed: a program director survey Vol. 97, Issue 4, 349
Hauer KE, Teherani A, Kerr KM. 2009. Student performance problems in medical school clinical skills assessments.University of California, San Francisco.
Tervo RC, Dimitrievich E, Trujillo AL, Whittle K, Redinius P, Wellman L. The Objective Structured Clinical Examination (OSCE) in the clinical clerkship: an overview.USD School of Medicine, Department of Pediatrics, Sioux Falls, SD, USA.
Miller, R | Masarie, F E | Myers, J D.1986. Quick Medical Reference (QMR) for diagnostic assistance. MD Computing. Vol. 3, no. 5, pp. 34-48.