Maxine A. Papadakis

Unprofessional Behavior in Medical School Is Associated with Subsequent Disciplinary Action by a State Medical Board

Purpose To determine if medical students who demonstrate unprofessional behavior in medical school are more likely to have subsequent state board disciplinary action. Method A case–control study was conducted of all University of California, San Francisco, School of Medicine graduates disciplined by the Medical Board of California from 1990–2000 (68). Control graduates (196) were matched by medical school graduation year and specialty choice. Predictor variables were male gender, undergraduate grade point average, Medical College Admission Test scores, medical school grades, National Board of Medical Examiner Part 1 scores, and negative excerpts describing unprofessional behavior from course evaluation forms, deans letter of recommendation for residencies, and administrative correspondence. Negative excerpts were scored for severity (Good/Trace versus Concern/Problem/Extreme). The outcome variable was state board disciplinary action. Results The alumni graduated between 1943 and 1989. Ninety-five percent of the disciplinary actions were for deficiencies in professionalism. The prevalence of Concern/Problem/Extreme excerpts in the cases was 38% and 19% in controls. Logistic regression analysis showed that disciplined physicians were more likely to have Concern/Problem/Extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15–4.02; p = .02). The remaining variables were not associated with disciplinary action. Conclusion Problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school.

Unpredictability of clinical evaluation of renal function in cirrhosis: Prospective study

The natural course of renal function in patients with cirrhosis and ascites but without azotemia is unclear. Therefore, a prospective evaluation of 23 non-azotemic cirrhotic patients with ascites was carried out over a three-year interval. Assessment included evaluation of serum electrolyte values, liver function tests, plasma renin levels, and parathyroid hormone levels. Renal function was determined by measurement of clearances of water and solute excretion, and simultaneous clearances of para-amino hippurate, inulin, and creatinine. The initial mean glomerular filtration rate was 66 ml/minute, serum creatinine level was 1.1 mg/dl, and blood urea nitrogen value was 13 mg/dl. The glomerular filtration rate showed marked variability among patients. On the basis of initial glomerular filtration rate, the patients were divided into three groups. Group I consisted of patients with supranormal filtration rates (mean 183 ml/minute), Group II constituted patients with normal filtration rates (mean 92 ml/minute), and Group III comprised patients with severely impaired filtration rates (mean 32 ml/minute). The serum creatinine level was below 1.5 mg/dl in all three groups. Serial measurement of renal function was performed in 18 patients over a mean of 310 days (range four to 1,176 days). Eighty-six percent of patients studied from Groups I and II maintained a normal or supranormal glomerular filtration rate over one year. However, most patients in Group III showed a progressive decline in filtration rate, despite no change in serum creatinine value. Sixty-seven percent of Group III patients died over a mean of one year. The mean 24-hour solute excretion among Group III patients was only 263 mOsm per day, significantly less than the control value of 874 mOsm per day in other hospitalized non-cirrhotic patients. The serum creatinine level frequently failed to rise above normal even when the glomerular filtration rate was very low (less than 25 ml/minute), and creatinine clearance overestimated inulin clearance by a factor of two in Group III patients. However, the creatinine index was an aid in determining true glomerular filtration rate and may be a useful clinical test in the evaluation of renal insufficiency in cirrhotic patients with normal serum creatinine values. Many patients with cirrhosis and ascites will have a glomerular filtration rate of less than 60 ml/minute but a normal serum creatinine level. These patients may constitute a previously unrecognized large group.

Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or below-standard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance.

Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board.

Background In a previous study, we showed that unprofessional behavior in medical school was associated with subsequent disciplinary action. This study expands on that work by identifying the domains of unprofessional behavior that are most problematic. Method In this retrospective case-control study, negative comments were extracted from student files for 68 case (disciplined) and 196 matched control (nondisciplined) physicians. Comments were analyzed qualitatively and subsequently quantified. The relationship between domains of behavior and disciplinary action was established through chi-square tests and multivariate analysis of variance. Results Three domains of unprofessional behavior emerged that were related significantly to later disciplinary outcome: (1) poor reliability and responsibility, (2) lack of self-improvement and adaptability, and (3) poor initiative and motivation. Conclusions Three critical domains of professionalism associated with future disciplinary action have been defined. These findings could lead to focused remediation strategies and policy decisions.

Mentorship through advisory colleges.

OBJECTIVE Medical students face pressures ranging from the need to create a social network to learning vast amounts of scientific material. Students often feel isolated in this system and lack mentorship. In order to counteract feelings of bureaucratic anonymity and isolation, the University of California San Francisco has created an advisory college to foster the professional and personal growth and well being of students. DESCRIPTION UCSF has developed a formal structure to advise medical students. A selection committee, chaired by the associate dean of student affairs, appointed five faculty mentors to head advisory colleges. These five colleges serve as the advising and well-being infrastructure for the students. Mentors were chosen from a balanced range of clinical disciplines, both primary and specialty. The disciplines are obstetrics-gynecology, otolaryngology/head and neck surgery, medicine, pediatrics, and psychiatry. The mentors have demonstrated excellence in advising and counseling of students. Mentors meet individually at the beginning of the academic year with incoming first-year and second-year students. They then have bimonthly meetings with eight to ten students within each college throughout the academic year. Curricula for these group sessions include well-being discussions and coping techniques, sessions on the hidden and informal curriculum of professionalism, and discussions on career choices and strategies. For third-year students, advisory college meetings are scheduled during intersessions, which are weeklong courses that occur between the eight-week clerkship blocks. Mentors are available throughout the year to meet with students on an as-needed basis, and advisory colleges may hold group social activities. The deans office supports each mentor with 20% salary and provides administrative support for the group college activities. DISCUSSION Historically, UCSF students feel they receive an excellent education and appropriate job opportunities, but they do not feel they receive adequate advising and mentoring. This may have as its root cause the financial, clinical, and research pressures placed upon a faculty who are also responsible for mentoring residents and fellows. The advisory colleges begin by providing an infrastructure for developing a relationship for the student with a single faculty member. The advisory college system is incorporated into the academic schedule rather than relying on ad-hoc activities from well-meaning but inconsistently available faculty. In the early part of medical school, the advisory college relationship concentrates on assimilation into the new environment and provides the student with advice pertaining to mastering academic material. The college also serves as a sounding board for problems that can then be relayed to course directors to improve the educational experience. For students encountering academic difficulty, the college advisor can provide discreet advice about tutoring resources and can direct the student to a separately staffed Student Well-being Program. As time progresses, the mentors can direct students to key people in different fields of interest such as program directors and keep the students on track to make career decisions in a timely manner. The college system can help transform an anonymous medical school experience into a supportive, rich environment.

Medical Students' Perspectives on and Responses to Abuse During the Internal Medicine Clerkship

Background: The abuse of medical students on clinical rotations is a recognized problem, but the effects on students and their responses warrant further study. Purpose: To determine the severity of student abuse and the effects of abuse on students during the internal medicine clerkship. Methods: Internal medicine clerks at 11 medical schools (N = 1,072) completed an exit survey. Students were asked whether they had been abused. If they had, they were asked about the severity of the abuse, whether they reported it, and its effects on them. Results: Of the responding students, 123 (11%) believed they had been abused. Only 31% of the students who felt abused reported the episodes to someone. The most common consequences of the events included poor learning environments, lack of confidence, and feelings of depression, anger, and humiliation. Conclusion: Students described a variety of personal and educational effects of abuse. They generally did not report abuse because of fear of retaliation and the belief that reporting is pointless.

Hyperkalemia Complicating Digoxin Toxicity in a Patient With Renal Failure

We describe the occurrence of hyperkalemia in a stable hemodialysis patient who developed digoxin toxicity. The patient had been receiving digoxin for 2 years. His maintenance digoxin dose was increased from 0.125 to 0.25 mg three times a week, which resulted in a toxic serum level of 4.9 ng/mL (therapeutic range is 0.8 to 2.0 ng/mL). As a consequence of the digoxin toxicity, he became hyperkalemic (7.8 mEq/L), and this value returned to normal only after the digoxin level was lowered by a combination of oral charcoal and dialysis. This study shows how readily hyperkalemia can occur in an anephric patient manifesting digoxin toxicity. Thus, potentially lethal hyperkalemia can occur in hemodialysis patients who ingest therapeutic quantities of digoxin. Digoxin toxicity should be added to the differential diagnosis of hyperkalemia in patients with renal failure. This can occur despite the absence of a history of massive ingestion of a cardiac glycoside.

The relationship between measures of unprofessional behavior during medical school and indices on the California Psychological Inventory.

Background Research studies on physicians disciplined by state medical boards showed specific types of unprofessional behavior were predictive of later disciplinary action. Similarly, law enforcement officers who received disciplinary action scored lower on certain scales of the California Psychological Inventory (CPI). Method This study used a case–control descriptive design and independent t tests to examine differences in scores on six psychological indices (CPI scales) by level of unprofessional behavior during medical school. Results Physicians who demonstrated unprofessional behavior during medical school versus those who did not scored significantly lower on four CPI scales. Results are consistent with findings in which general unprofessional behavior during medical school can be further characterized to domains of irresponsibility, lack of self-improvement, and poor initiative. Conclusions The psychological indices of the CPI scales differed by level of unprofessional behavior, which leads one to wonder whether the use of personality measures should be considered during the admissions process to medical school.

Specialty Certification Status, Performance Ratings, and Disciplinary Actions of Internal Medicine Residents.

Purpose Little is known about the attrition of physicians trained in internal medicine (IM). The authors sought to examine career paths, disciplinary actions, and American Board of Medical Specialties (ABMS) certification status of IM residents. Method Three datasets were combined to study 66,881 residents in Accreditation Council for Graduate Medical Education–accredited IM residency programs nationwide from 1995 to 2004. Group differences (among an American Board of Internal Medicine [ABIM]-certified cohort; an ABMS-certified cohort (but not ABIM-certified); and a noncertified cohort) in IM residency performance ratings, specialty certification status, year of initial IM training, and medical board disciplinary actions were examined. Analyses included chi-square tests, analysis of variance, pairwise comparisons, and logistic regressions. Results Ninety-five percent of IM residents obtained ABIM certification; 1.6% received ABMS certification in another specialty; 3.4% received no ABMS specialty certification, of which 74.3% have a current medical license; and 66.6% self-reported IM as their primary specialty. During residency, the ABIM cohort performed better than those who never obtained ABIM certification. Disciplinary actions were lowest for the ABIM cohort (1.2%), 2.4% for the ABMS cohort, and highest and more severe for the noncertified cohort (6.0%). Conclusions Only 5% of IM residents do not achieve IM certification. IM resident attrition minimally impacts physician supply, though those without certification appear to contribute disproportionately to poor physician performance indicators. Improved tracking of the U.S. physician workforce could aid policy makers in predicting manpower shifts in certain specialty areas, both during and after residency training.

Assessment of the Contributions of Clinician Educators

Clinician educators play a vital role at medical schools. The number of clinician educators and the scope of their responsibility have grown at academic medical centers over the last two decades 1 . Clinician educators provide expert patient care that has become critical to the financial viability of medical centers. Clinician educators also teach and supervise medical students and residents in the inpatient and, increasingly, in the ambulatory setting 2 . Despite clinical expertise and enthusiasm and skill for teaching, clinician educators face many challenges in sustaining and growing their academic careers. They experience varying and often unclear criteria by which their qualifications for promotion are judged. Clinical departments lack consistent measures to assess expertise in clinical care and teaching, and frequently default to evaluating clinician educators using criteria designed for researchers 2 . However, clinician educators typically shoulder large clinical commitments that make it difficult or impossible for them to produce scholarship at a level comparable to those with substantial protected time for