The Slippery Concept of “Professionalism” in Residency is a Problem

Last Updated on April 17, 2024 by Laura Turner

Residents and fellows in ACGME-accredited training programs know well that “Professionalism” is one of the six core competencies they are to develop during their training. As I have expressed in the past, though, professionalism is a catch-all competency frequently cited as a basis for remediation and discipline. And the subjectivity of the value judgments that inform evaluations of professionalism makes this competency one that is ripe for abuse in disciplining trainees.

A new piece in The New York Times by Rachel E. Gross shines a light on this problem, which deserves the full attention of the ACGME, the AAMC, specialty boards, licensing boards, medical schools, and residency and fellowship programs. Consistent with my experience and that of countless other trainees, Ms. Gross wrote: “Depending on who makes the call, unprofessional behavior can mean hugging your program director, letting a bra strap show, wearing braids, donning a swimsuit over the weekend or wearing a ‘Black Lives Matter’ sweatshirt in the E.R.” And, more troubling still, because trainees of color appear to be disproportionately falling victim to dismissals from programs (constituting 20% of dismissals while representing just 5% of trainees, per 2015-16 data), there is concern that cultural or racial biases—conscious or unconscious—are at work.

There is an increasing amount of scholarship around this issue, including a recent article that concluded that a resident’s race/ethnicity was associated with assessment scores, to the disadvantage of residents who are underrepresented in medicine (i.e., Black, Hispanic/Latinx, and Native American physicians). The association may reflect bias in faculty assessment, effects of a non-inclusive learning environment, or structural inequities in assessment. This same article also found that male faculty rated residents who are underrepresented in medicine 0.13 points lower in professionalism than non-underrepresented residents, whereas women faculty rated underrepresented residents 0.01 points higher than their represented counterparts.

For its part, the ACGME has denounced racism, implicit bias, and other forms of discrimination in graduate medical education. It points to, among other things, its Common Program Requirements that mandate a “professional, equitable, respectful, and civil environment that is free from discrimination, sexual and other forms of harassment, mistreatment, abuse, or coercion of students, residents, faculty, and staff.” However, in an article published in the December 2023 issue of the Journal of Graduate Medical Education, the authors wrote that “[r]acial and gender bias appears to exist in Accreditation Council for Graduate Medical Education competencies and Milestone achievement, as some studies have found that White residents attain a higher level of Milestone achievement than non-White trainees.”

Bear in mind, also, that the ACGME Common Program Requirements instruct program directors and faculty to be role models, especially in the realm of professionalism. To this point, the ACGME’s September 2017 CLER Issue Brief on professionalism noted that “[p]rofessionalism is not solely an individual responsibility; it is shaped by the environment.” In other words, programs can hardly expect trainees, who are taking cues from the behavior of their attendings, to take seriously alleged deficiencies in their professionalism that are tolerated in their attendings. In an environment where meeting expectations is paramount to progression towards independent practice, residency, and fellowship programs owe their trainees a clear and consistent application of those expectations from top to bottom.

While the debate on the best methods of pre-empting bias from occurring is underway, including training and mitigation of implicit biases, there are still hundreds of residents presently being subjected to unfair remediation and discipline based on amorphous concepts like professionalism. Sophisticated or well-informed programs and institutions feel emboldened to do so because of an expectation that the courts will not interfere with their ostensible “academic judgment.” This is where the ACGME can and must step in to put an end to the open-ended and nebulous concept of professionalism that ensnares so many promising residents and fellows. Sponsoring institutions and programs sorely need an authoritative statement on the boundaries of professionalism, including what is and is not a deficiency in professionalism as defined by the Common Program Requirements.

Moreover, the ACGME must require that the “due process” it requires for non-promotions, non-renewals, suspensions, and dismissals cannot be satisfied merely by asking, mechanically, if the various steps in the disciplinary process were done. This is a mockery of due process that is now very much en-vogue at institutions across the country. It robs the trainee, at the most pivotal moment in their career, of a critical review of whether the underlying allegations merit the consequences the program is meting out. At least in that circumstance, the reviewer or panel of reviewers can judge (hopefully, objectively) whether the alleged lapses in professionalism that have become all too slippery are actually present and whether they can be remediated.

We have regularly represented residents and fellows for over a decade in large and small matters. We know which strategies can provide leverage and opportunities for success. Contact us to see how we can put that experience to work for you. I would urge all medical residents and fellows facing remediation, probation, warning, reprimand, or letters of concern or counseling to reach out to see how we can assist. A version of this article was previously published on the Brown, Goldstein & Levy webpage.