Unprofessional behaviour

By R Ali 

Updated: 21st October 2023 

Case 3:

A medical student is assigned to work with a GP tutor in a busy clinic. The student is late for the clinic, unprepared for their patients, and doesn't complete their notes. The GP is concerned. This student's suspected unprofessional behaviour could put patients at risk and disrupt the clinic. What can the GP tutor do?

Unprofessional behaviour in medical students can have a negative impact on patients, other students, and the entire healthcare team. GP tutors play a vital role in identifying and addressing unprofessional behaviour early on. By being aware of unprofessional behaviour, and by developing a plan for responding to it, GP tutors can help to create a safe and supportive learning environment for all students.

Guiding principles and terminology 

• Unprofessional behaviour in medical students: behaviour that undermines the trust of patients, peers, teachers, and society in the medical profession. It can be categorized into four domains: lack of involvement, integrity, interaction, or introspection.  Doctors must be professional to provide good health care. It is not only desirable for doctors to be professional, but it is also required to protect patients and improve their care. Unprofessional behaviour by medical students can affect other students, teachers, healthcare teams, and patients.

• Professionalism, professional behaviour, and professional identity formation: three different viewpoints in medical education and research. Professionalism is the adherence to high ethical and moral standards. Professional behaviour is the demonstration of professionalism in specific situations. Professional identity formation is the process of acquiring and integrating professionalism knowledge, skills, and judgment into one's developing identity. 

• Professional lapses are part of learning: Educators should be ready to help students learn from their mistakes when they are unprofessional. Students can learn that unprofessional behaviour is not accepted because it harms patients.

• Papadakis's study showed that unprofessional behaviour in medical school is a strong predictor of unprofessional behaviour as a doctor. This makes it clear that medical schools and tutors should not allow unprofessional behaviour.

• Clinical and medical educators find it difficult to address unprofessional behaviour, leading to the "failure to fail" phenomenon. Finding ways to describe and categorize unprofessional behaviour can encourage teachers to take action. Reasons for this include

  • a lack of conceptual clarity about (un)professionalism in medical school,

  • concern for the subjectivity of one’s judgment,

  • fear of harming a student’s reputation,

  • lack of appropriate faculty development, and

  • uncertainty about the remediation process and its outcomes

• Recognise neurodiversity:  People with neurodiverse conditions may experience challenges with communication, social interaction, organization, and time management. These challenges can sometimes lead to unprofessional behaviour in medical students. For example, a student with autism may have difficulty communicating effectively with patients or they may become overwhelmed in a busy clinic setting. A student with ADHD may be disorganized and forgetful, which could lead to missed appointments or incomplete patient notes.  It is important to note that not all students with neurodiverse conditions will exhibit unprofessional behaviour. However, it is important for educators to be aware of the challenges that these students may face and to be prepared to provide support.

• Adopt a positive response (instead of a negative response): Medical students should be taught and encouraged to be professional doctors, rather than simply being punished for unprofessional behavior.

• The 4 I's model: a model that comprises 30 descriptors for unprofessional behaviours in medical students, indicating a deficiency in four domains: involvement (e.g. absenteeism, lack of preparation), integrity (e.g. cheating, dishonesty), interaction (e.g. disrespect, poor communication), and introspection (e.g. defensiveness, lack of insight). 

• Behavioural profiles: a way of grouping unprofessional behaviours into 

  • four profiles 

    • accidental behaviour,

    • struggling behaviour, 

    • gaming-the-system behaviour and 

    • disavowing behaviour), 

  • distinguished by two dimensions 

    • reflectiveness and 

    • adaptability. 

These profiles can help educators to identify and remediate different types of unprofessional behaviour in different types of students.

• Factors contributing to unprofessional behaviour: triggers for the occurrence of unprofessional behaviour that can originate from personal issues (e.g. stress, burnout), interpersonal issues (e.g. conflict, harassment), external factors (e.g. social media, legal issues), and contextual factors (e.g. hidden curriculum, organizational culture).

• Three-phase roadmap for responding to unprofessional behaviour: a practical guide for educators to handle unprofessionalism in medical students. The three phases are: 

  • explore and understand (using the Theory of Planned Behaviour or the Onion model to assess the student's intentions and beliefs), 

  • remediate (using pedagogical measures such as feedback, mentoring, coaching, or counselling to support the student's learning objectives and improvement), and 

  • gather evidence for dismissal (for students who show persistent or egregious unprofessional behaviour despite remediation).

• Consider and suspect: we use these words in clinical practice (see NICE suspected cancer guidance). Consider is means to think about but not sufficient to act on. Suspect means that there is sufficient concern to take action. For example, a student may turn up late (first time), consider and exclude unprofessional behaviour by identifying a suitable explanation.

Behavioural theories

The Theory of Planned Behaviour (TPB) is a psychological theory that links beliefs to behaviour. It was developed by Icek Ajzen in 1985 as an extension of the Theory of Reasoned Action (TRA). The TPB maintains that three core components, namely, attitude, subjective norms, and perceived behavioural control, together shape an individual's behavioural intentions. In turn, a tenet of TPB is that behavioural intention is the most proximal determinant of human social behaviour.

The onion model of behaviour is a metaphor for the different layers of factors that influence human behaviour. The model is often used in psychology, sociology, and business to understand how people make decisions and act.

The onion model has four layers:

• Outer layer: The outer layer represents the visible aspects of behaviour, such as actions, words, and expressions. These are the things that other people can see and observe.

• Middle layer: The middle layer represents the internal factors that influence behaviour, such as thoughts, feelings, and beliefs. These are the things that are not visible to others, but they play a major role in shaping our behaviour.

• Inner layer: The inner layer represents our core values and personality traits. These are the things that are most deeply rooted within us and they tend to be relatively stable over time.

• Center: The center of the onion represents our unconscious mind. This is the part of our mind that we are not aware of, but it can still have a powerful influence on our behaviour.

Barron's Expectancy-Value-Cost model to suggest some ways for educators to respond to unprofessional behaviour. The model says that people are motivated to do or not do something based on 

• how likely they think they are to succeed or the expectancy (can I do it?)

• how important they think it is or the value (do I want to do it?)

• how difficult it will be or the cost (are there barriers that will stop me?)

GMC's key concern areas 

• persistent inappropriate attitude or behaviour

• failing to demonstrate good medical practice

• drug or alcohol misuse

• cheating or plagiarizing

• dishonesty or fraud

• aggressive, violent or threatening behaviour.

Workshop plan

Goal: To help GP tutors understand and address unprofessional behaviour in medical students

Needs of learners: tutors may encounter unprofessional behaviour in their students, such as lack of involvement, integrity, interaction, or introspection. They may feel reluctant or unsure how to respond to such behaviour and how to provide effective feedback and remediation.

Outcomes: GP tutors should be able to:

• Understand general principles & terminology of unprofessional and professional behaviour

• Define and recognize unprofessional behaviour in medical students using the 4 I's model and the behavioural profiles.

• Identify and address the factors that contribute to unprofessional behaviour in students, such as personal, interpersonal, external, and contextual factors.

• Apply a three-phase roadmap for responding to unprofessional behaviour: explore and understand, remediate, and gather evidence for dismissal.

Tensions and dilemmas

• Tension between addressing the behaviour and protecting the student's privacy: Medical students are often reluctant to report unprofessional behaviour because they fear that it will damage their reputation or jeopardize their career. Educators need to be sensitive to these concerns and ensure that students feel safe to report unprofessional behaviour without fear of reprisal.

• Tension between being fair and consistent and being compassionate and understanding: Unprofessional behaviour can have a range of causes, from personal problems to mental health challenges. Educators need to be able to assess each situation on a case-by-case basis and develop a response that is both fair and compassionate.

• Tension between maintaining a professional environment and supporting students who may be struggling: Unprofessional behaviour can create a hostile and uncomfortable learning environment for other students and staff. Educators need to be able to balance the need to maintain a professional environment with the need to support students who may be struggling.

• Tension between wanting to help students learn and grow and wanting to protect patients: Unprofessional behaviour by medical students can put patients at risk. Educators need to be able to balance the need to help students learn and grow with the need to protect patients.

Cases 

Case 1:

A medical student is on placement at a GP practice. They are assigned to shadow a doctor during a home visit to an elderly patient. The patient is frail and has dementia. The student is rude and disrespectful to the patient, and they do not follow the doctor's instructions.

Case 2:

A medical student is on placement at a GP practice. They are assigned to work in the reception area. The student is rude and dismissive to patients when they come to the desk. The student also spends most of their time on their phone or chatting to other staff, instead of helping patients.

Case 3:

A medical student is on placement at a GP practice. They are assigned to work with a doctor during a clinic. The student is late for appointments and they do not prepare for their patients. The student also makes careless mistakes in their notes.

Questions 

• What are the underlying causes of unprofessional behaviour in medical students?

• How can we create a learning environment that is both supportive and challenging?

• How can we balance the need to address unprofessional behaviour with the need to protect the student's privacy and future career?

• How can we develop fair and consistent responses to unprofessional behaviour?

• How can we help students who are struggling to learn and grow in a professional manner?

• How can we protect patients from the risks of unprofessional behaviour by medical students?

References

A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity. (2019). Medical Teacher. [online] doi:https://doi.org/10.1080/0142159X.2018.1464133

Carmelle Peisah, Williams, B., Hockey, P., Lees, P., Wright, D.J. and Rosenstein, A.H. (2023). Pragmatic Systemic Solutions to the Wicked and Persistent Problem of the Unprofessional Disruptive Physician in the Health System. Healthcare, [online] 11(17), pp.2455–2455. doi:https://doi.org/10.3390/healthcare11172455. 

Gmc-uk.org. (2023). Achieving good medical practice: guidance for medical students. [online] Available at: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/student-professionalism-and-ftp/achieving-good-medical-practice  [Accessed 21 Oct. 2023].

How to identify, address and report students’ unprofessional behaviour in medical school. (2020). Medical Teacher. [online] doi: https://doi.org/10.1080//0142159X.2019.1692130

Neurodiversity in medical education: How can we improve postgraduate learning for neurodiverse doctors? (2022). Medical Teacher. [online] doi:https://doi.org/10.1080//0142159X.2022.2039383. 

Sattar, K., Akram, A., Ahmad, T. and Bashir, U. (2021). Professionalism development of undergraduate medical students. Medicine, [online] 100(9), pp.e23580–e23580. doi:https://doi.org/10.1097/md.0000000000023580.