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.

(cut)

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.

Walking on Eggshells With Trainees in the Clinical Learning Environment—Avoiding the Eggshells Is Not the Answer.

Gold MA, Rosenthal SL, Wainberg ML.
JAMA Pediatr. 
Published online August 05, 2019.
doi:10.1001/jamapediatrics.2019.2501

Here is an excerpt:

Every trainee inevitably will encounter material or experiences that create discomfort. These situations are necessary for growth and faculty should be able to have the freedom in those situations to challenge the trainee’s assumptions.5 However, faculty have expressed concern that in the effort to manage the imbalance of power and protect trainees from the potential of abuse and harassment, we have labeled difficult conversations and discomfort as maltreatment. When faculty feel that the academic institution sides with trainees without considering the faculty member’s perspective and actions, they may feel as if their reputation and hard work as an educator has been challenged or ruined. For example, if a trainee reports a faculty member for creating a “sexually hostile” environment because the faculty has requested that the trainee take explicit sexual histories of adolescents, it may result in the faculty avoiding this type of difficult conversation and lead to a lack of skill development in trainees. Another unintended consequence is that trainees will not gain skills in having difficult conversations with their faculty, and without feedback they may not grow in their clinical expertise. As our workforce becomes increasingly diverse and we care for a range of populations, the likelihood of misunderstandings and the need to talk about sensitive topics and have difficult conversations increases.

There are several ways to create an environment that fosters the ability for trainees and faculty to walk across eggshells without fear. It is important to continue medical school training regarding unconscious bias, cultural sensitivity, and communication skills. This should include helping trainees not only apply these skills with each other and with their patients but also with their faculty. Trainees are likely to have as many unconscious biases toward their faculty as their faculty have toward them. For example, one study found that at one institution, female medical school faculty were given significantly lower teaching evaluations by third-year medical students in all clerkship rotations compared with male medical school faculty. Pediatrics showed the second largest difference, with surgery having the greatest difference.

The info is here.