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Around the time of publication of the book Teaching Medical Professionalism,1 literature on remediation of unprofessional behavior of learners and practitioners in medicine had just begun to emerge in earnest, no doubt reflecting developments in accreditation of graduate medical education programs and health facilities as well as concern for patient safety. The book’s chapter on the topic2 summarized the extant publications, along with the authors’ experience in addressing professional lapses of learners in academic medicine. Much of the work covered in the chapter provided prescriptions for how to proceed with the process of remediation: general approaches to remediation, policies to follow, steps to take including the development of a detailed remediation plan, and suggestions for specific remediation techniques. Apparent themes emphasized changing the behavior of the individual learner or practitioner and the crucial role of assessment in identifying and defining a lapse, as well as determining whether remediation had been successful. Factors thought to predict success or failure of the attempt to correct unprofessional behavior were proposed, including the individual’s recognition that a problem exists, her subscription to the values of medical professionalism, a genuine desire to change her behavior, acceptance of the responsibility to participate in remediation, and her demonstration of accountability during the process.2 Program factors predictive of remediation success included early recognition of the problem, creation of a remediation plan with transparent goals, specific remediation activities, and frequent performance feedback under the guidance of a mentor–advisor who models professional behavior, administers the plan consistently, and in fact gives frequent feedback.2 Despite the existence of this wisdom from experts, there was recognition that remediation of unprofessional behavior was challenging and not always successful, with the likelihood of relapses and outright failures.
In the years since publication of Teaching Medical Professionalism to the present, the remediation literature has grown substantially. An emphasis on steps in the remediation process and techniques to address unprofessional behavior remains,3–21 while recognition of the relationship between professional lapses and patient safety has grown.9,16,18,22–25 Appreciation of the role of the environment has intensified, and specific recommendations for building environments supportive of effective remediation as well as professionalism have been formulated.9,15–18,25–28 Attention paid to the interaction between the environment and the individual in causing, addressing, and preventing unprofessional behavior has emerged.7,19,22,23,28–30 And well-considered advice about conducting remediation of unprofessional behavior has become increasingly elaborated.9,19,20,31 A summary of the advice available in the extant literature appears at the end of this chapter.
Several articles report that remediation of unprofessional behavior has been effective,18,32,33 but the recognition continues of how challenging successful remediation can be.3,33,34 Difficulties previously discussed in the literature endure: a belief that unprofessional behavior is not fixable; reluctance to report professional lapses based on questions about the definition and assessment of professionalism including whether altruism is tenable; concern about the validity of allegations; poor knowledge about procedural matters and remediation techniques; distaste for confrontation; fear of litigation; and indecision about when unprofessional behavior becomes so intolerable that the learner or practitioner has no place in medicine.
Although the literature and experience with remediation of professional lapses have blossomed, a major gap exists: carefully researched evidence on best practices is typically missing.8,11,35 An exception is the Vanderbilt University Medical Center’s considerable work that is a model for studies of the effectiveness of remediation policies and practices, as well as a model for those policies and practices in and of themselves.18 Still, effective remediation is not ensured.
Perhaps an antidote to limited success with remediation and gathering evidence for effective intervention lies in a new trend in the remediation literature. The trend begins to apply social science theories about social and psychological development in adulthood to conceptualizing and implementing remediation of unprofessional behavior. Theories of self-determination, self-efficacy, constructivism, development of moral reasoning and behavior, and especially formation of professional identity are promising.
Thus, this chapter examines remediation of unprofessional behavior through a theoretical lens, particularly that of professional identity development. It addresses how the theories of professional identity formation could frame general approaches to remediation by:
Explaining components of the theories relevant to remediation;
Exploring the implications of these theoretical insights for changing how we think about remediation;
Describing current practices compatible with identity development and remediation;
Specifying next steps to advance the application of identity formation theory to remediation policies and practices and potentially enhance the success of remediation efforts and the development of professional identity among learners and practitioners in medicine;
Suggesting future research studies; and
Components of identity formation theories relevant to remediation of unprofessional behavior
The psychological and sociocultural processes underlying professional identity formation and their implications for professionals and professional students have received increased attention over the past few years and have been thoroughly presented elsewhere.36–39 There are several components of identity formation theories that are especially relevant to remediation of unprofessional behavior. Identification and discussion of these components follow.
Fundamental to remediation of unprofessional behavior is the view that professional identity formation is a life-long process consisting of a near constant negotiation between an individual’s own internal values, adopted roles, personality and external influences, including other individuals, communities of practice (workplaces, institutions, professional organizations, medical profession),40 and explicit and implicit cultural messages from the environment.37–39 Another basic concept in professional identity formation is that individuals advance and regress along three interdependent levels: the individual, the environment, and the interaction between the individual and the environment.37–39 These three sets of processes occur simultaneously, but for the sake of providing an organizational structure of this chapter each will be discussed in turn.
The individual
Theories of professional identity formation describe the journey that an individual takes to build her own professional identity. They recognize that learners in medicine do not enter training programs as a blank slate ready to adopt the professional identities endorsed by their eventual communities of practice.39 Rather, they arrive with a set of ascribed identities, such as “Woman,” “Hispanic,” and “Heterosexual,” that have been cultivated almost from birth. They also bring their own set of achieved identities, such as “Musician,” “Athlete,” and “Scholar.” Everyone has multiple identities, and the ways in which individuals reconcile those identities have implications for professional identity formation. Social identity complexity theory categorizes the ways in which individuals reconcile multiple identities in terms of the extent to which the identities are perceived as overlapping.41 At the most simplified level, the individual views others who are members of the same set of social identities as in-group members (intersection). For example, a heterosexual, Hispanic medical student will see other heterosexual, Hispanic medical students as part of her in-group; everyone else is part of the out-group. At the most complex level, the individual views others who hold any one social identity in common as in-group members (merger). The heterosexual, Hispanic medical student would see anyone who is heterosexual, or Hispanic, or a medical student as part of her in-group. Individuals with more complex social identity structures tend to be more open to experiences, tolerant of ambiguity, and accepting of differences than individuals with more simple social identity structures. It is important to note that when individuals are experiencing stress, or are engaged in activities that require substantial cognitive effort, they tend to resort to more simplified social identity structures even if their typical social identity structure may be more complex. As explained later, this set of idiosyncratic identities has implications for an individual’s ability to construct a professional identity sanctioned by his or her community of practice.41
The theories often describe the individual’s journey of identity formation as moving from one stage to the next. For example, Kegan’s42 identity development stage theory posits that on their way to developing an internalized, self-authored identity where they are able to successfully negotiate and integrate their multiple identities including the values of the profession (stage 4), individuals first move through a stage focused on achieving external goals to meet their own needs (stage 2) and a stage where they define themselves through the relationships they have (stage 3). Some argue that Kegan’s stage 5, where individuals are able to fully contextualize their identity and understand that there are multiple valid ways to act in accordance with one’s core beliefs, is very rarely achieved and remains aspirational for most.36,38 These stage theories, including Kegan’s model, provide useful benchmarks that indicate where individuals fall along the continuum of professional identity formation.
Other theories point to mechanisms that can promote movement from one stage to the next. Constructivist learning theory in particular underscores the importance of knowing the stage of individuals’ development as a necessary first step in facilitating movement toward an integrated, internalized identity. Given that knowledge, the right amount of challenge can be provided to move individuals into a state of disequilibrium along with the scaffolding necessary to keep individuals in their zone of proximal development.43 A primary mechanism that guides development is indeed scaffolding, when more experienced members of the social environment provide assistance or model appropriate behavior or thought processes. Additionally, the potential for growth is greatest when the individual is in the zone of proximal development, a state in which the individual can complete a given task with scaffolding. The zone of proximal development lies in the space between where the individual can complete a task independently and where the individual cannot complete the task even with expert guidance. In short, balancing the levels of challenge and of support is crucial for encouraging growth without overwhelming individuals to such an extent that they are not able to cope.43
In addition, other theories posit (and empirical studies suggest) that the flow from one stage to the next is not always seamless.36,38,44 The learners’ road to becoming a physician is perilous, consisting of a series of discontinuities and crises to work through as they internalize what it means to be a student, resident, and physician.38 Each discontinuity and each crisis present an opportunity for growth and for making mistakes. Likewise, individuals who are dealing with a major stressor may stagnate on their developmental trajectory or even regress to a more familiar way of thinking about and acting in their environment, manifesting in behavior deemed unprofessional by the community of practice.41 Given the discontinuities and crises encountered during the process of professional identity formation, individuals experience a wide range of emotions, both negative and positive, that medical educators often have not taken into account.45
Finally, individual learners and practicing physicians may not be as far along the developmental continuum as might be intuitively expected. Research has shown that many individuals do not reach the higher stages of identity development until they are well into adulthood.36,46 Because identity development is a process of negotiation involving inputs from the environment that are ever changing, including shifting roles throughout the life cycle and the task of integrating various aspects of the self into a coherent whole, identity development may be most properly conceptualized as not only ongoing but also life-long.
The environment
Professional identity formation theory maintains that the socialization process that takes place when individuals enter into and maintain their membership in a community of practice acts on individuals in a powerful way.37–39 Foremost are the influences of role models (peers, near peers, practicing physicians) and mentors and participation in apprenticeships offering authentic experiences with ever increasing integration into communities of practice.47 Environments characterized by positive institutional cultures, clearly articulated policies and practices, and zero tolerance of frank substandard professional behavior are also key.16 Other recognized environmental factors include opportunities for learners and practitioners to observe behavior, talk about experiences in safe environments, reflect on those experiences under the guidance of seasoned professionals, and self-assess one’s own behavior.47
Self-determination theory (SDT) offers recommendations to structure our environments in ways that can foster positive growth in professional identity formation.48,49 Individuals who wish to join or maintain membership in a particular community of practice will work toward engendering a sense of relatedness with the community by internalizing and integrating the community’s beliefs, practices, and values. The explicit and implicit socialization processes employed within communities of practice have varying degrees of success in facilitating individuals’ internalization and integration of the communities’ norms and values. Central to SDT is the role the environment plays in facilitating whether an individual is motivated to act by her own internalized and integrated goals and values (autonomous motivation) or by external pressures such as rewards and punishments (controlled motivation). The behaviors and activities that are driven by autonomous motivation are the ones most likely to contribute to positive identity formation. Environments that foster a sense of competence, autonomy, and relatedness (i.e., when individuals believe that they can be successful in the activities they choose to engage in and feel personally connected to others in their environment) tend to promote autonomous motivation. On the other hand, when individuals feel externally controlled and disconnected from leaders in the community of practice and are required to engage in activities that are either under- or overly challenging, the likelihood that they will internalize the desired behaviors and values is quite low; rather, they tend to exhibit the desired behaviors only when pressured externally.48,49
Role modeling and mentoring are potent mechanisms that transmit the characteristics of the environment to individuals. Theory and empirical work show that role models have a substantial impact on learners’ and physicians’ professional behavior.47,50–56 Students, residents, and faculty have reported that the primary way they learn professionalism is through role modeling.50,53–55 See Chapter 6. Further, individuals report the influence on learning professionalism not just from positive role models but also negative role models.50,52–55 Role modeling often has a powerful and positive influence on individuals’ professional behavior; however, role models are not always positive models. Individuals regularly witness faculty members, residents, and students engaging in unprofessional behavior.54,57–62 The role that negative role models play in influencing professionalism has the potential to be deleterious.52,57,58,61,62
The interaction between the individual and the environment
An individual’s unique set of ascribed and achieved identities, coupled with his or her current stage of identity formation, interacts with the environment and leads individuals to construct their unique professional identity.39,63 In some cases, the match between the individual’s identity and the community of practice’s notions of what it means to be a member are congruent, making it relatively painless to begin to integrate. For others, the match-up is not so straightforward, often leading the individual into a state of identity dissonance, where she struggles to negotiate between maintaining her identity and adopting the professional identity being imposed by the community of practice.63
Identity dissonance is a mechanism that causes some individuals to restructure their identity, much like cognitive disequilibrium functions for constructivists. Others who experience identity dissonance may actively reject the professional identity being imposed by the community of practice, frequently leading to alienation and sometimes extreme struggles within their community of practice.63 Working through a state of identity dissonance can often cause major emotional and cognitive upheaval63 and may be a ripe time to make professionalism lapses; likewise, others’ reactions to a professional lapse may be enough to push an individual into a state of identity dissonance. Individuals who are not able to successfully work through a state of intense identity dissonance to a place of identity congruence are precisely the individuals who need special attention in the form of a remediation plan.
In addition to tensions between already internalized identities and identities that are being prescribed by the environment, there are also tensions between competing messages sent by the environment. There are conflicting discourses within medical schools; one focused on standardization, as exemplified by a competency approach, and the other focused on diversity, as exemplified by admissions committees’ beliefs that each student is unique and brings singular gifts to the educational experience that enrich others in the environment.64 The two discourses are in tension, although both aim at providing the best possible care to patients. The way learners internalize the competing discourses is strongly influenced by the identities and the social identity structures they have already constructed, leading them to embrace one discourse over the other, or meld the two.64
Implications of professional identity formation theory for remediation
If identity formation is an ongoing process, then remediation might best be considered as a life-long continuous quality improvement activity for the development of a professional identity, incumbent upon each member of the profession, including the student and the resident through to the most senior of physicians. An unexamined identity would not be acceptable, since such an identity ignores changes during the life cycle of roles.
Remediation of behavior incompatible with identities accepted by communities of practice, including the professional lapse caused by issues with professional identity formation and the lapse due to other factors such as illness of the individual, a toxic environment, or a mismatch between the individual and the environment, becomes a matter of continuous quality improvement. This conceptualization of remediation then transforms the goal of remediation as not only a matter of changing inappropriate behavior, but also of developing a professional identity accepted by the community of practice. In other words, remediation for professional lapses would become a special case of continuous quality improvement, since all members of the profession must participate in ongoing professional identity assessment and development. Given that, remediation of a professional lapse may lose some of its stigma, and the process may proceed more easily.
In the paradigm shift toward looking at professionalism remediation through the lens of professional identity development, another important stigma to overcome is the very common belief that professionalism is an innate quality not amenable to change. Labeling behavior as bad is a social process often coupled with the notion that professionalism is innate and cannot be taught or changed, leading us to label the individual as bad or unprofessional. Using the new framework, we can shift our understanding of unprofessional behavior from innate and immutable to a normal part of an individual’s development toward an identity that has more fully internalized and integrated the practices, beliefs, and values of the community of practice. That being said, it is still important for a community of practice to establish its own red line, so individuals understand that some kinds of behavior are unacceptable and will not be tolerated. Each school of medicine and clinical practice needs to have clear codes of conduct for professional behavior and accompanying policies that delineate the consequences for individuals when their behavior crosses the red line. It is up to individual communities of practice to determine under what contexts and with which behaviors it is appropriate to engage continuous professional development or remediation strategies and when the behaviors require disciplinary action.
Viewing professional lapses through the lens of professional identity formation might point to more fundamental issues that are problematic, involving not only the content of a learner’s values and attitudes but also the way in which the individual structures those values and attitudes.42 For example, in an early stage of professional identity development, a medical student subscribes to the pursuit of excellence, an aspirational value of medical professionalism. But in aiming at achieving outstanding performance of valued role behaviors such as high scores on examinations, the medical student does not collaborate on a group project (which contributes little value to a final course grade), but chooses to prepare for an end-of-semester test by herself in order to “ace” it (which is most heavily weighted in the computation of a final grade). Her focus derives from her own need to achieve that external goal of top grade, and it defines who she is. She is not concerned about how her peers regard her: she believes they cannot help her achieve a top score on the test and indeed that working with them on the project could diminish her chances for getting the top grade. The remediation process then might usefully involve discussions about higher levels of professional identity that go beyond a preoccupation with one’s own needs and interests, and thus may get at the core of the student’s problem rather than just a discussion of meeting expectations for attendance and participation in group projects. As this example illustrates, identity formation theory provides deeper insight into a possible cause of unprofessional behavior: arrested development reflecting achievement of only beginning stages of the journey to a professional identity acceptable to the community of practice.
Theories of identity formation identify yet another potential trigger of unprofessional behavior because this behavior brings to the fore the possibility that the individual has not yet fully achieved a coherent sense of self that resolves potential conflicts between various identities to the point of fully subscribing to aspirational professional values as primary drivers. In particular, as an example, learners’ and clinicians’ discomfort with or outright rejection of altruism as service to others may be understood as a manifestation of an unsettled clash between the professional identity and family identities such as spouse, parent, or child. This disequilibrium or dissonance brings its own emotional upheaval, but also might be a spur to further development of the professional identity. By viewing the cause of the clash in terms of achieving a coherent sense of self, the magnitude of the task of improving the alignment of aspirations toward professional values as part of the self with other identities is recognized, but is also perhaps a source of resolution, aligning aspirations with professional values. As the example suggests, identity development theory not only identifies a cause of unprofessional behavior but also offers leverage into creation of a more appropriate remediation plan.
In addition, the theory underscores the importance of environmental factors, already recognized as contributing to professional behavior and discussed above. Identity formation theory suggests the need, not widely acknowledged, for educational opportunities to learn about, discuss, and reflect on the process of identity formation itself, its course and characteristics, and ways to fashion a trajectory moving toward the final aspirational stage. Mentors sharing their journeys can be powerful tools in this regard.
The goal in fostering positive professional identity formation is that individuals embody the norms, beliefs, and practices valued by the community of practice and do so of their own volition, and in all of the contexts in which they find themselves. That is, we want individuals to act from a place of autonomous motivation after having fully internalized and integrated the community of practice’s highest aspirational professionalism principles.48,49 However, environments in medicine and medical education are sometimes criticized for being structured in such a way as to elicit motivation through controlling and coercive methods rather than through methods that SDT labels as autonomy-supportive, leading individuals to act in desirable ways only when externally pressured to do so.49 The characteristics of an ideal environment for facilitating autonomous motivation and the internalization of practices and values include:
Taking individuals’ perspectives into account;
Communicating expectations in an empathetic manner;
Explaining the rationale for implementing new policies and practices;
Allowing individuals to choose their own activities and behaviors whenever possible; and
Providing opportunities to participate in reasonably challenging activities with the provision of nonjudgmental feedback.48,49
The theory’s emphasis on the environment prompts the suggestion that any plan to enable individuals to move to a more advanced stage of development or to remediate unprofessional behavior must be built upon identification of which environmental elements that could promote growth have been missing in the individual’s experience. In other words, investigation of which environmental factors mentioned above have been missing or inadequate in the experience of the learner or practicing physician could guide more targeted selection of solutions to the problem and shape a potentially more effective remediation plan.
Current practices compatible with identity development formation theory and remediation
If educators, supervisors, physicians in training, and even practicing physicians embrace the concept of identity formation as a continuous process of growth and development, it follows that this belief can be incorporated into the view of a physician’s professionalism as a life-long improvement opportunity. Within this model, even exemplars of professionalism can strive to enhance their skills and work on taking their achievements beyond their own identity and influencing professionalism within systems and organizations. Therefore, within this framework, the process of remediation of individuals who do not meet professionalism standards becomes more readily accepted as a quality improvement activity in which everyone participates – in contrast to a punitive process. However, even in this model, it would be necessary to accept that there are unprofessional behaviors that might not be amenable to remediation.
Practical expressions of the continuous performance improvement model can readily be seen in expectations set for the development of medical students, residents and fellows, practicing physicians, and for the environment itself. Reviewing some current practice examples can frame the concept of professionalism as a continuous improvement opportunity throughout the life of a physician and the organizations and systems in which he or she practices.
The individual
For medical students, the Association of American Medical Colleges has developed core “entrustable professional activities” (EPAs) as a set of requisite skills that students must demonstrate by the time of graduation to help ensure successful transition from the role of student to that of resident.65 Critical to the development and implementation of all the EPAs is the foundation of student trustworthiness and self-awareness of personal limitations paired with self-directed guidance to improve.65 As an example, to fulfill the expectations of the EPA “[c]ollaborate as a member of an interprofessional team,” students must not only demonstrate their role and acknowledge their limits as a team member, they must also accept that the team supersedes their personal interests and that they have a responsibility to assist team members.65 While the EPAs describe expected behaviors, the demonstration of those behaviors helps define the identity of a successful student prepared to transition to residency. The Association of Faculties of Medicine of Canada (AFMC) has similarly worked to define requirements during critical transition stages in the life of physician development from student to resident to independent practice.66
The Accreditation Council for Graduate Medical Education (ACGME) recognizes that development of skills in residents and fellows is a progression with certain expectations to be mastered by the time of completion of training. As part of the Next Accreditation System, milestone landmarks have been crafted for each specialty, including achievements in professionalism. Training programs are required to measure the achievement “level” of the milestones for each trainee every six months until she completes the program.67 The milestones are intended to demonstrate the progression of a resident’s individual knowledge, skills, and attitudes as she achieves competence to enter independent practice.68 For this discussion of professionalism as a continuous improvement process, we reviewed the milestones in professionalism of the core hospital-based, medical, and surgical specialties. The specialties (anesthesiology, diagnostic radiology, emergency medicine, family medicine, internal medicine, pathology, pediatrics, psychiatry, obstetrics and gynecology, ophthalmology, orthopedic surgery, and surgery) differed in the number of milestones devoted to professionalism but shared themes representing highest achievements.69–80 The aspirational or uppermost accomplishments in professionalism describe individuals taking professionalism beyond actions and behaviors of themselves and relationships with patients to include contributions to and impacts on systems, teams, and organizations.69–80 Examples include developing policies and procedures regarding professionalism, serving as a resource and mentor for those not meeting standards (such as working with impaired colleagues), fostering collegiality to promote teamwork, and modeling constructive feedback (both providing and receiving criticism).69–80 Such individuals are viewed as leaders and mentors for professionalism.
By implementing milestone assessment for their learners, residency programs can determine if an individual trainee is progressing, is stagnant, or is regressing in professionalism achievements. In doing so, the milestones can provide guidance to program directors (PDs) regarding the current expression of professionalism in each resident or fellow and serve as a first step to recommending remediation goals for those not meeting standards. The professionalism lapse can then be viewed as an opportunity for growth and development in each learner.
Practicing physicians know that maintenance of certification for both the American Board of Medical Specialties (ABMS) and the Royal College of Physicians and Surgeons of Canada requires the practitioner to participate in performance improvement and life-long learning activities. For physicians certified by the ABMS, the diplomate must demonstrate a commitment to professional responsibilities including adherence to ethical principles and the demonstration of humanism, compassion, and acceptance of diversity to patients, healthcare teams, and physician self-care.81 The AFMC further mandates physician self-regulation, both individually and collectively, as an obligation to the profession including remediation and discipline of those not meeting predefined standards.82
Environment
Institutions are required to implement continuous quality improvement activities related to the environments in which students, residents, fellows, and practicing physicians work and learn. The Liaison Committee for Medical Education (LCME) and ACGME require, as part of the accreditation process, educational programs to conduct self-studies examining the effectiveness of professionalism current practices and identifying opportunities for improvement. The ACGME has implemented the Clinical Learning Environment Review (CLER) process as an assessment of the current system in which residents and fellows learn. This process encourages institutions and hospital systems to work cooperatively in a continuous quality improvement effort to enhance the learning environment for GME.83 Professionalism is one of the six focus areas examined in the clinical setting. Specifically, the review investigates how residents, fellows, and faculty are educated about professionalism; which attitudes, beliefs, and skills of residents and fellows are related to professionalism; how faculty are engaged in professionalism training; and how the clinical site monitors professionalism.84 The goal of the CLER is to enhance the integration of residents, fellows, and faculty members in hospital systems to promote the learning environment and patient care.
Perhaps the greatest example of practicing continuous quality improvement of healthcare environments are the changes in the healthcare delivery and monitoring systems that arose from initiatives by The Joint Commission (TJC) and other organizations to improve patient quality care and safety. It has become all too common for healthcare professionals to work in silos disconnected from their colleagues, which undermines their sense of relatedness in the work environment. The recent and welcome focus on interprofessional collaboration and education may be a boon to individuals who feel isolated and disconnected. Working in a team on which all members are valued for their individual contributions could go a long way toward building a sense of relatedness.
Concern for quality care and patient safety has also prompted proposals to construct a culture supportive of professional behavior in educational and clinical settings. One proposal views respect as the essential ingredient in achieving a nurturing environment and stipulates that institutions must develop effective methods for responding to episodes of disrespectful unprofessional behavior while initiating cultural changes necessary to prevent such episodes.16 An excellent model of a comprehensive approach to this task, including the remediation of unprofessional behavior, entails three programs nested in a center for patient and professional advocacy.28 The center advances the institution’s values for safety, quality, and professionalism; offers continuing medical education courses; and sponsors a faculty physician wellness program, a physician assessment program focusing on fitness for duty, and a committee for awareness intervention. Perhaps at the pinnacle of that institution’s approach is a carefully tested mentoring program for physicians who do not meet professionalism standards, which demonstrates how the institution actively implemented an environmental process to promote professionalism among physicians.18 Physicians who were identified by patients’ and families’ complaints as not meeting professionalism standards received intervention and intense mentoring by trained peer mentors. The process included sharing of the complaint, physician self-reflection, and on-going advising and feedback regarding patient interactions. The authors concluded that intensive, persistent, and professional sharing with physician outliers acknowledged the fact that they differed from their peers and the prospect that they could improve their performance was necessary to successful remediation. Promoting accountability of every physician for her actions could ultimately enhance the overall environment.
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