Unprofessionalism in anesthesiology: A qualitative study on classifying unprofessional behavior in anesthesiology residency education.

STUDY OBJECTIVE: This study aims to identify the domains that constitute behaviors perceived to be unprofessional in anesthesiology residency training programs. DESIGN: Qualitative study. SETTING: Anesthesiology residency training programs. PATIENTS: Not applicable. The participants involved residents, fellows, and faculty members purposefully sampled in four US-based anesthesiology residency programs. INTERVENTIONS: Participants were asked to submit examples of unprofessional behavior they witnessed in anesthesiology residents, fellows, or faculty members via a Qualtrics link. MEASUREMENTS: Not applicable. The behavior examples were independently reviewed and categorized into themes using content analysis. MAIN RESULTS: A total of 116 vignettes were collected, resulting in a final list of 111 vignettes after excluding those that did not describe behavior exhibited by anesthesiology faculty or trainees. Fifty-eight vignettes pertained to unprofessional behaviors observed in faculty members and 53 were observed in trainees (residents and fellows). Nine unprofessionalism themes emerged in the analysis. The most common themes were VERBAL, SUPERVISION, QUALITY, ENGAGEMENT, and TIME. As to the distribution of role group (faculty versus trainee) by theme, unprofessional behaviors falling into the categories of BIAS, GOSSIP, LEWD, and VERBAL were observed more in faculty; whereas themes with unprofessional behavior primarily attributed to trainees included ENGAGEMENT, QUALITY, TIME, and SUPERVISION. CONCLUSION: By reviewing reported professionalism-related vignettes within residency training programs, we identified classification descriptors for defining unprofessional behavior specific to anesthesiology residency education. Findings from this study enrich the definition of professionalism as a multi-dimensional competency pertaining to anesthesiology graduate medical education. This framework may facilitate preventative intervention and timely remediation plans for unprofessional behavior in residents and faculty.

Self-Reported Academic Misconduct among Medical Students: Perception and Prevalence.

Academic integrity is the basis of an education system and must be taught as an ethical behavior during academic training. Students who reflect honesty and truthfulness during the academic years are more likely to follow this path, develop professional integrity, and thus become responsible and dependable professionals. Here, we determine the prevalence of academic lapses among medical students by a cross-sectional descriptive survey based on a self-assessment questionnaire. Students' perception of 37 behaviors comprising five domains, plagiarism, indolence, cheating, disruptive behavior, and falsifying data, were explored. A high percentage of students (83%) indicated that all 37 behaviors constitute misconduct. Approximately 65% of students thought that their fellow students were involved in dishonest behaviors, and 34% answered that they were indulged in some form of misconduct. Content analysis identified some prevalent behaviors such as doing work for another student (82.5%), getting information from the students who already took the exam (82.5%), copying the answer from neighbors (79%), and marking attendance for absent friends (74.5%). Multiple regression analysis points out that future indulgence in a behavior is significantly (p ≤ 0.5) correlated with understanding a behavior as wrong, perceiving that others do it and whether one has already indulged in it. This study can serve as a diagnostic tool to analyze the prevalence of misconduct and a foothold to develop the medical school system's ethical guidelines.

Multiple United States Medical Licensing Examination Attempts and the Estimated Risk of Disciplinary Actions Among Graduates of U.S. and Canadian Medical Schools.

PURPOSE: The United States Medical Licensing Examination (USMLE) recently announced 2 policy changes: shifting from numeric score reporting on the Step 1 examination to pass/fail reporting and limiting examinees to 4 attempts for each Step component. In light of these policies, exam measures other than scores, such as the number of examination attempts, are of interest. Attempt limit policies are intended to ensure minimum standards of physician competency, yet little research has explored how Step attempts relate to physician practice outcomes. This study examined the relationship between USMLE attempts and the likelihood of receiving disciplinary actions from state medical boards. METHOD: The sample population was 219,018 graduates from U.S. and Canadian MD-granting medical schools who passed all USMLE Step examinations by 2011 and obtained a medical license in the United States, using data from the NBME and the Federation of State Medical Boards. Logistic regressions estimated how attempts on Steps 1, 2 Clinical Knowledge (CK), and 3 examinations influenced the likelihood of receiving disciplinary actions by 2018, while accounting for physician characteristics. RESULTS: A total of 3,399 physicians (2%) received at least 1 disciplinary action. Additional attempts needed to pass Steps 1, 2 CK, and 3 were associated with an increased likelihood of receiving disciplinary actions (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 1.01, 1.13; OR: 1.09, 95% CI: 1.03, 1.16; OR: 1.11, 95% CI: 1.04, 1.17, respectively), after accounting for other factors. CONCLUSIONS: Physicians who took multiple attempts to pass Steps 1, 2 CK, and 3 were associated with higher estimated likelihood of receiving disciplinary actions. This study offers support for licensure and practice standards to account for physicians' USMLE attempts. The relatively small effect sizes, however, caution policy makers from placing sole emphasis on this relationship.

Why Otolaryngologists Get Excluded From Medicare and Medicaid.

The List of Excluded Individuals and Entities (LEIE) is a federally updated and available list of providers who have been excluded from participating from federal healthcare programs. With over 40 year's worth of exclusion history, we were able to isolate and identify otolaryngologists who were excluded and the most common cause, albeit exceptionally rare, was revocation of their medical license due to negligence.

The prevalence and impact of unprofessional behaviour among hospital workers: a survey in seven Australian hospitals.

OBJECTIVE: To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees. DESIGN, SETTING, PARTICIPANTS: Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 - Nov 2018) about their experience of unprofessional behaviours - 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) - and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking-up skills. MAIN OUTCOME MEASURES: Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self-reported speaking-up skills. RESULTS: Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9-94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5-40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6-15.5%) reported extreme unprofessional behaviour. Nurses and non-clinical staff members aged 25-34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self-reported speaking-up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46-0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67-0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38-0.51). CONCLUSIONS: Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.

Abuse and disrespectful care on women during access to antenatal care services and its implications in Ndola and Kitwe health facilities.

BACKGROUND: Antenatal care utilization is fundamental in preventing adverse pregnancy and birth outcomes. This paper assessed abuse and disrespectful care on women during access to antenatal care services and its implications in Ndola and Kitwe districts of Zambia. METHODS: The assessment used a cross-sectional study design with a sample size of 505 women of child bearing age (15-49). Eighteen (18) high volume health facilities were identified as benchmarks for catchment areas (study sites) and using cluster sampling, households within catchment areas of health facilities were sampled. Chi-square and poison regression analysis was performed to ascertain associations between abuse and disrespect and antenatal care utilization. RESULTS: One third (33%) of the participants attended less than half of the recommended antenatal visits. Results reveal a statistical significant association between; physical abuse (p value = 0.039); not being allowed to assume position of choice during examination (p value = 0.021); not having privacy during examination (p value = 0.006) and antenatal care service utilization. The difference in the logs of expected count on the number of antenatal care visits is expected to be; 0.066 (CI: -0.115,-0.018) unit lower for women who experienced lack of privacy during examinations; 0.067 (CI: -0.131,-0.004) unit lower for women who were discriminated based on specific attributes and 0.067 (CI: -0.120,-0.014) unit lower for women who were left unattended. CONCLUSION: Abuse and disrespect during antenatal care service impedes demand for health care and service utilization thereby barricading the element of the package of services aimed at improving maternal and newborn health.

Academic dishonesty among university students: The roles of the psychopathy, motivation, and self-efficacy.

Academic dishonesty is a common problem at universities around the world, leading to undesirable consequences for both students and the education system. To effectively address this problem, it is necessary to identify specific predispositions that promote cheating. In Polish undergraduate students (N = 390), we examined the role of psychopathy, achievement goals, and self-efficacy as predictors of academic dishonesty. We found that the disinhibition aspect of psychopathy and mastery-goal orientation predicted the frequency of students' academic dishonesty and mastery-goal orientation mediated the relationship between the disinhibition and meanness aspects of psychopathy and dishonesty. Furthermore, general self-efficacy moderated the indirect effect of disinhibition on academic dishonesty through mastery-goal orientation. The practical implications of the study include the identification of risk factors and potential mechanisms leading to students' dishonest behavior that can be used to plan personalized interventions to prevent or deal with academic dishonesty.

Isn't high school bad enough already? Rates of gender harassment and institutional betrayal in high school and their association with trauma-related symptoms.

Germinal studies have described the prevalence of sex-based harassment in high schools and its associations with adverse outcomes in adolescents. Studies have focused on students, with little attention given to the actions of high schools themselves. Though journalists responded to the #MeToo movement by reporting on schools' betrayal of students who report misconduct, this topic remains understudied by researchers. Gender harassment is characterized by sexist remarks, sexually crude or offensive behavior, gender policing, work-family policing, and infantilization. Institutional betrayal is characterized by the failure of an institution, such as a school, to protect individuals dependent on the institution. We investigated high school gender harassment and institutional betrayal reported retrospectively by 535 current undergraduates. Our primary aim was to investigate whether institutional betrayal moderates the relationship between high school gender harassment and current trauma symptoms. In our pre-registered hypotheses (https://osf.io/3ds8k), we predicted that (1) high school gender harassment would be associated with more current trauma symptoms and (2) institutional betrayal would moderate this relationship such that high levels of institutional betrayal would be associated with a stronger association between high school gender harassment and current trauma symptoms. Consistent with our first hypothesis, high school gender harassment significantly predicted college trauma-related symptoms. An equation that included participant gender, race, age, high school gender harassment, institutional betrayal, and the interaction of gender harassment and institutional betrayal also significantly predicted trauma-related symptoms. Contrary to our second hypothesis, the interaction term was non-significant. However, institutional betrayal predicted unique variance in current trauma symptoms above and beyond the other variables. These findings indicate that both high school gender harassment and high school institutional betrayal are independently associated with trauma symptoms, suggesting that intervention should target both phenomena.

Association Between Web-Based Physician Ratings and Physician Disciplinary Convictions: Retrospective Observational Study.

BACKGROUND: Physician rating websites are commonly used by the public, yet the relationship between web-based physician ratings and health care quality is not well understood. OBJECTIVE: The objective of our study was to use physician disciplinary convictions as an extreme marker for poor physician quality and to investigate whether disciplined physicians have lower ratings than nondisciplined matched controls. METHODS: This was a retrospective national observational study of all disciplined physicians in Canada (751 physicians, 2000 to 2013). We searched ratings (2005-2015) from the country's leading online physician rating website for this group, and for 751 matched controls according to gender, specialty, practice years, and location. We compared overall ratings (out of a score of 5) as well as mean ratings by the type of misconduct. We also compared ratings for each type of misconduct and punishment. RESULTS: There were 62.7% (471/751) of convicted and disciplined physicians (cases) with web-based ratings and 64.6% (485/751) of nondisciplined physicians (controls) with ratings. Of 312 matched case-control pairs, disciplined physicians were rated lower than controls overall (3.62 vs 4.00; P<.001). Disciplined physicians had lower ratings for all types of misconduct and punishment-except for physicians disciplined for sexual offenses (n=90 pairs; 3.83 vs 3.86; P=.81). Sexual misconduct was the only category in which mean ratings for physicians were higher than those for other disciplined physicians (3.63 vs 3.35; P=.003). CONCLUSIONS: Physicians convicted for disciplinary misconduct generally had lower web-based ratings. Physicians convicted of sexual misconduct did not have lower ratings and were rated higher than other disciplined physicians. These findings may have future implications for the identification of physicians providing poor-quality care.

Speak-Up Culture in Academic Nursing: Empowering Junior Faculty.

BACKGROUND: Faculty-to-faculty incivility in academic nursing is well documented, yet speaking up about the unprofessional behaviors of academic colleagues is still a challenge, particularly for junior faculty. METHOD: A unique faculty development session presented an opportunity to explore junior faculty experiences and perceptions of incivility, with the objectives of addressing concerns in a safe environment, identifying appropriate responses and resources for managing incivility, and supporting decisional influences on speaking up. RESULTS: Junior faculty were valued for their unique perspectives of the institutional culture and empowered as members of speak-up culture in the academic setting. CONCLUSION: Administrators benefit from intentionally seeking junior faculty perspectives regarding unprofessional faculty behaviors in the academic setting. Overall school culture benefits from ongoing efforts toward discussion, resource development, and upholding policies related to incivility. [J Nurs Educ. 2020;59(4):210-213.].

An Innovative Civility Intervention Created by a Faculty and Student Action Research Team.

BACKGROUND: Incivility is a significant issue in nursing education and practice, contributing to ineffective learning, unprofessional nursing practice, and negative patient outcomes. METHOD: A team of nursing faculty and students used Action Research to develop a quality improvement project targeting civility. A two-part, evidence-based training was offered to prelicensure nursing students, faculty, and staff. Part one was designed to increase incivility awareness, and part two was intended to enhance communication skills. RESULTS: Program evaluation data were collected through an anonymous survey and analyzed descriptively for themes. Results indicated students, faculty, and staff perceived the educational innovation as valuable and useful. CONCLUSION: By using free resources, a college of nursing was able to implement a cost-effective program to begin a conversation and offer a communication strategy to address incivility for students, faculty, and staff. This program design can be adopted by others for use in their organization. [J Nurs Educ. 2020;59(4):214-217.].

Providers' perceptions of disrespect and abuse during childbirth: a mixed-methods study in Kenya.

Disrespect and abuse during childbirth are violations of women's human rights and an indicator of poor-quality care. Disrespect and abuse during childbirth are widespread, yet data on providers' perspectives on the topic are limited. We examined providers' perspectives on the frequency and drivers of disrespect and abuse during facility-based childbirth in a rural county in Kenya. We used data from a mixed-methods study in a rural county in Western Kenya with 49 maternity providers (32 clinical and 17 non-clinical) in 2016. Providers were asked structured questions on disrespect and abuse, followed by open-ended questions on why certain behaviours were exhibited (or not). Most providers reported that women were often treated with dignity and respect. However, 53% of providers reported ever observing other providers verbally abuse women and 45% reported doing so themselves. Observation of physical abuse was reported by 37% of providers while 35% reported doing so themselves. Drivers of disrespect and abuse included perceptions of women being difficult, stress and burnout, facility culture and lack of accountability, poor facility infrastructure and lack of medicines and supplies, and provider attitudes. Provider bias, training and women's empowerment influenced how different women were treated. We conclude that disrespect and abuse are driven by difficult situations in a health system coupled with a facilitating sociocultural environment. Providers resorted to disrespect and abuse as a means of gaining compliance when they were stressed and feeling helpless. Interventions to address disrespect and abuse need to tackle the multiplicity of contributing factors. These should include empowering providers to deal with difficult situations, develop positive coping mechanisms for stress and address their biases. We also need to change the culture in facilities and strengthen the health systems to address the system-level stressors.

Sexual misconduct by health professionals in Australia, 2011-2016: a retrospective analysis of notifications to health regulators.

OBJECTIVES: To assess the numbers of notifications to health regulators alleging sexual misconduct by registered health practitioners in Australia, by health care profession. DESIGN, SETTING: Retrospective cohort study; analysis of Australian Health Practitioner Regulation Agency and NSW Health Professional Councils Authority data on notifications of sexual misconduct during 2011-2016. PARTICIPANTS: All registered practitioners in 15 health professions. MAIN OUTCOME MEASURES: Notification rates (per 10 000 practitioner-years) and adjusted rate ratios (aRRs) by age, sex, profession, medical specialty, and practice location. RESULTS: Regulators received 1507 sexual misconduct notifications for 1167 of 724 649 registered health practitioners (0.2%), including 208 practitioners (18%) who were the subjects of more than one report during 2011-2016; 381 notifications (25%) alleged sexual relationships, 1126 (75%) sexual harassment or assault. Notifications regarding sexual relationships were more frequent for psychiatrists (15.2 notifications per 10 000 practitioner-years), psychologists (5.0 per 10 000 practitioner-years), and general practitioners (6.4 per 10 000 practitioner-years); the rate was higher for regional/rural than metropolitan practitioners (aRR, 1.73; 95% CI, 1.31-2.30). Notifications of sexual harassment or assault more frequently named male than female practitioners (aRR, 37.1; 95% CI, 26.7-51.5). A larger proportion of notifications of sexual misconduct than of other forms of misconduct led to regulatory sanctions (242 of 709 closed cases [34%] v 5727 of 23 855 [24%]). CONCLUSIONS: While notifications alleging sexual misconduct by health practitioners are rare, such misconduct has serious consequences for patients, practitioners, and the community. Further efforts are needed to prevent sexual misconduct in health care and to ensure thorough investigation of alleged misconduct.

Patients' complaints involving ophthalmologists in the province of Ontario, Canada: a 5-year review.

OBJECTIVE: To present an overview of complaints against ophthalmologists to the regulatory body in the province of Ontario, Canada, during a 5-year period. DESIGN: Retrospective cross-sectional study. METHODS: All completed complaints to the College of Physicians and Surgeons of Ontario (CPSO) involving ophthalmologists from January 2013 to May 2018 were reviewed. Data regarding the prevalence of complaints, physician characteristics, practice location, reason of complaint, and outcomes as decided by the Inquiries, Complaints and Reports Committee (ICRC) were collected. Identified concerns were classified across 3 domains: clinical care and treatment, professionalism and conduct, and practice management. RESULTS: There were 372 complaints involving 211 ophthalmologists out of 448 practicing ophthalmologists in Ontario. A total of 933 issues were raised in the 372 complaints. Complaints related to clinical care and treatment were most common (76.3%), followed by professionalism and conduct (55.4%) and practice management (24.7%). Within these domains, the 5 largest subcategories in order of occurrence were communication, billing practices, consent, procedural mishap, and documentation. Of the 372 investigations, the ICRC took some form of action in 117 cases (31.4%). The most common actionable decisions issued by the ICRC were advice (19.1%), caution (6.2%), and participation in a specified continuing educational or remediation program (3.5%). Four cases (1.1%) were referred to the Discipline Committee. CONCLUSIONS: Almost half of practicing ophthalmologists in Ontario (47%) received at least one formal CPSO complaint within the 5-year study period. Communication was the most common issue raised in complaints.

For a honest Maghreb care system. Systematic Review of the International Literature on Corruption in the Health care System.

INTRODUCTION: Corruption in the health care system is a universal phenomenon, putting at risk the health of populations. The purpose of this work was to synthesize the international literature on corruption in the health sector. METHODS: This is a systematic review of literature dealing with articles on health corruption practices, published between July 2008 and June 2018, via two search engines: PubMed and Google Scholar. The extracted data were narratively summarized in three major areas: defining the concept of corruption in health, its typology / manifestations and anti-corruption interventions. RESULTS: A total of 23 articles were selected for final analysis. The articles that defined health corruption shared two key aspects: "abuse of power" and "benefit". The main types of corruption were "abuse of therapeutic indication", followed by "bribes" and "falsification". The anti-corruption interventions were synthesized into seven types: creation of an independent multi-interventional agency, support for scientific research, law enforcement, awareness raising, detection, reporting and institutional commitment. CONCLUSION: Based on the use of power, corruption in health is a complex phenomenon whose struggle requires a specific and contextualized strategy integrating information, detection and punishment.

See No Evil, Hear No Evil, Stop No Evil: Institutional-Level Tracking to Combat Mistreatment of Residents and Fellows.

BACKGROUND: Mistreatment of trainees, including discrimination and harassment, is a problem in graduate medical education. Current tools to assess the prevalence of mistreatment often are not administered institutionally and may not account for multiple sources of mistreatment, limiting an institution's ability to respond and intervene. OBJECTIVE: We describe the utility of a brief questionnaire, embedded within longer institutional program evaluations, measuring the prevalence of different types of trainee mistreatment from multiple sources, including supervisors, team members, colleagues, and patients. METHODS: In 2018, we administered a modified version of the mistreatment questions in the Association of American Medical Colleges Graduation Questionnaire to investigate the prevalence and sources of mistreatment in graduating residents and fellows. We conducted analyses to determine the prevalence, types, and sources of mistreatment of trainees at the institutional level across graduate medical education programs. RESULTS: A total of 234 graduating trainees (77%) from the University of Minnesota-Twin Cities completed the questions. Patients were cited as the primary source of mistreatment in 5 of 6 categories, including both direct and indirect offensive remarks, microaggressions, sexual harassment, and physical threats (paired t test comparisons from t = 3.92 to t = 9.71, all P < .001). The only category of mistreatment in which patients were not the most significant source was humiliation and shaming. CONCLUSIONS: Six questions concerning types and sources of trainee mistreatment, embedded within an institutional survey, generated new information for institutional-, departmental- and program-based future interventions. Patients were the greatest source for all types of mistreatment except humiliation and shaming.

A focused mapping review and synthesis of a priori risk factors associated with medical misconduct.

Background: Medical misconduct is an international problem. It is judged according to whether a doctor has endangered the health of the public. Little is known about the risk factors associated with medical misconduct. To inform patient safety, we undertook a focused mapping review and synthesis (FMRS) of tribunal reports retrieved from the Medical Practitioners Tribunal Service (MPTS). Methods: A four-phase FMRS was undertaken: (1) identification and retrieval of 1-year tribunal transcripts from the MPTS (focus), (2) analysis of transcripts to identify patterns mapped to 'a priori' risk factors (mapping), (3) peer review of the data (calibration) and (4) creation of a risk profile (synthesis). Results: Out of the 351 investigative tribunals, 249 (70.94%) resulted in a guilty verdict. 82.73% of all guilty verdicts led to the removal of the doctor from practice. Through the identification of four a priori risk factors, we developed a model of risk associated with medical misconduct: (1) being male, (2) primary medical qualification (PMQ) outside of the UK, (3) working within general practice and surgical specialties, and (4) having passed PMQ more than 20 years ago. Notable 'unconfirmed' factors, such as locum work, PMQ achieved outside of the European Union, increasing age and lack of clinical guidance are also relevant to what is deemed professional behaviour and what is not. Conclusions: The findings can inform debates about patient safety and lay the groundwork for further research into medical misconduct. Prospective studies should focus on confirming the contributory factors and relationship between these four a priori risk factors for medical misconduct: being male, PMQ outside of the UK, increasing age and working in general practice or surgical settings.