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Thursday, March 19, 2020

Responding to Unprofessional Behavior by Trainees — A “Just Culture” Framework

J. A. Wasserman, M. Redinger, and T. Gibb
New England Journal of Medicine
February 20, 2020
doi: 10.1056/NEJMms1912591

Professionalism lapses by trainees can be addressed productively if viewed through a lens of medical error, drawing on “just culture” principles. With this approach, educators can promote a formative learning environment while fairly addressing problematic behaviors.

Addressing lapses in professionalism is critical to professional development. Yet characterizing the ways in which the behavior of emerging professionals may fall short and responding to those behaviors remain difficult.

Catherine Lucey suggests that we “consider professionalism lapses to be either analogous to or a form of medical error,” in order to create “a ‘just environment’ in which people are encouraged to report professionalism challenges, lapses, and near misses.” Applying a framework of medical error promotes an understanding of professionalism as a set of skills whose acquisition requires a psychologically safe learning environment.

 Lucey and Souba also note that professionalism sometimes requires one to act counter to one’s other interests and motivations (e.g., to subordinate one’s own interests to those of others); the skills required to navigate such dilemmas must be acquired over time, and therefore trainees’ behavior will inevitably sometimes fall short.

We believe that lapses in professional behavior can be addressed productively if we view them through this lens of medical error, drawing on “just culture” principles and related procedural approaches.


The Just Culture Approach

Thanks to a movement catalyzed by an Institute of Medicine report, error reduction has become a priority of health systems over the past two decades. Their efforts have involved creating a “culture of psychological safety” that allows for open dialogue, dissent, and transparent reporting. Early iterations involved “blame free” approaches, which have increasingly given way to an emphasis on balancing individual and system accountability.

Drawing on these just culture principles, a popular approach for defining and responding to medical error recognizes the qualitative differences among inadvertent human error, at-risk behavior, and reckless behavior (the Institute for Safe Medication Practices also provides an excellent elaboration of these categories).

“Inadvertent human errors” result from suboptimal individual functioning, but without intention or the knowledge that a behavior is wrong or error-prone (e.g., an anesthesiologist inadvertently grabbing a paralyzing agent instead of a reversal agent). These errors are not considered blameworthy, and proper response involves consolation and assessment of systemic changes to prevent them in the future.