Increasing demands and changes in the healthcare system can both positively and negatively impact professional behavior. In light of the #MeToo movement, the focus on workplace behavior has intensified. As a follow-up to a session presented at the National Orthopaedic Leadership Conference in June, a symposium at the AAOS Fall Meeting in San Antonio, Texas, titled “Professional Behavior 2.0: How Medical Systems Influence Professional Behavior and What To Do About It,” explored work stressors and their impact on professionalism, as well as ways to encourage professional behavior.

Charlene M. Dewey, MD, MEd, FACP, of the Vanderbilt University School of Medicine, began by discussing the relationship between wellness and unprofessional behavior. She noted four types of major lapses in professionalism:

1. distressed behaviors
2. sexual boundary violations
3. improper prescribing
4. impairment

Dr. Dewey said unprofessional behavior can be the result of individual (psychological factors, mental health issues, genetic/developmental issues, family systems, stress, burnout, and reduced wellness) and institutional (poor/unsafe culture, dysfunctional systems, poor leadership, and institutional pathology) sources and can manifest as passive, aggressive, and passive-aggressive behaviors.

Unprofessional behavior in the workplace can result in increased liability and risk, loss of finances and reputation, reduced patient safety, poor/unsafe work environment, poor communication, and staff turnover. “I saw an example in which three people left because one physician was distressed and no one in the leadership took a step to change that individual’s behavior,” she said.

Professional health and wellness are the foundation for professionalism. “It’s not just the individual, it’s the culture and the environment in which they work that influence both their professional health and wellness,” she said.

Dr. Dewey then discussed how her institution developed an approach to provide psychological support to all faculty. In 1999, Vanderbilt began a specialized Faculty and Physician Wellness Program that utilizes a work-based, internal Employee Assistance Program model. The program was established to meet the growing needs of professionals coping with stress, depression, addiction, and other emotional and behavioral issues. Since implementation, more than 1,000 faculty members and physicians have received care through the program, 90 percent of whom were self-referred. “We represent wellness programs and activities for every partner in our institution,” she said. “We can’t make changes if we only address the individual sources.”

Dr. Dewey concluded by asking the audience, “If you could change one thing at your institution, what approach would you most like to address?” More than half said they would address workflow solutions from an organizational approach.

Next, Kevin J. Bozic, MD, MBA, chair of the Department of Surgery & Perioperative Care of Dell Medical School at the University of Texas, Austin, shared the American Board of Medical Specialties’ definition of professionalism: “[Medical professionalism] is a belief system in which the group’s members (“professionals”) declare (“profess”) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals.”

Professional misconduct by physicians is a significant problem with negative implications in the healthcare environment that can lead to a shift in attention from the patient to the surgeon, increased mistakes during procedures, deterrence from careers for trainees, and diminished respect for surgeons, according to Dr. Bozic. Burnout is particularly associated with professionalism, especially the depersonalization dimension of burnout that is associated with behavior and patient satisfaction.

“When you think about how we develop as professionals, it really starts with professional attitude,” he said. “And that attitude starts to develop very early on, way before we get to medical school.” Responsibility, maturity, respect, and communication skills are the core responsibilities of medical training, he said, but “how do you actually teach professionalism?”

Dr. Bozic said it starts with setting expectations; prevention of poor behavior should be the key, and remediation should occur when there is an issue. “It’s all about the culture that you develop,” he said.

Dr. Bozic then detailed his facility’s “unique opportunity” to incorporate professionalism training. Dell Medical School is the first U.S. medical school in 50 years to be built on a tier-one research campus. “We are really starting from scratch,” said Dr. Bozic, noting that professionalism must be taught and cannot simply be expected from residents or trainees.

He said the organization has a resident faculty wellness committee project that includes didactic exercises, as well as experiential learning and practical application exercises. “[The exercises] really give everyone the opportunity to emotionally process things associated with patient care,” he said.

They also have a formal escalation process and encourage students and trainees to speak out about unprofessional behavior and concerns. Beyond teaching principles of professionalism, the organization also asks residents to rate themselves to be able to understand “how we are doing.” The residents also receive constant feedback and encouragement based on observed behavior. So far, the trainees have said the activities and curriculum were contributing to growth in this area. “[Our organization was] encouraged that residents felt they were getting adequate training and professionalism and that they understood the importance of this in their clinical training,” Dr. Bozic said.

Professionalism is a critical core competency. “These are not things that you can just assume that our students and trainees are going to really absorb over time,” said Dr. Bozic, noting that program leaders and organizations need to take a purposeful approach to teaching this behavior. He stressed that developing professional attitudes, values, and behaviors starts in medical school, continues throughout training and practice, and requires lifelong learning.

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at kefitzgerald@aaos.org.