Remediating Lapses in Professionalism

Abstract

This chapter describes how medical educators can use measures of moral reasoning and professional identity formation to provide students with a diagnostic assessment of strengths and shortcomings in their understanding of the ethical and moral dimensions of professionalism. In addition to providing examples of programs designed to address an event for an individual or group (e.g., cheating, subpar behavior in practice), the authors highlight strategies they have found effective in therapeutic interactions with students who present particular challenges.

Appendices

Appendix A

1.1 Interpreting DIT-2 Results

In the first session of this course, I explained briefly that four abilities are needed to effectively resolve complex professional problems:

• 1. Moral sensitivity: the ability to recognize ethical issues in situations we encounter

• 2. Moral judgment: the ability to apply moral principles or ideals when developing a solution

• 3. Moral motivation and commitment: the ability to distinguish between competing values and commit to the moral value

• 4. Moral character and competence: the ability to develop and carry out a concrete set of plans to effectively resolve the moral dilemma

The DIT-2 (the assessment you completed during Session One) deals specifically with moral judgment—the ability to distinguish among moral arguments that appeal to the different justifications one could use to resolve a moral dilemma. The DIT-2 and that which it measures, moral reasoning and judgment, have been shown to relate to a wide range of prosocial behaviors, including the clinical performance of health care professionals.^{3 4 5}

1.2 Review of the DIT-2

The DIT-2 asked you to consider several dilemmas. The problems are dilemmas because many people feel they cannot be fairly resolved by simply applying explicit rules or laws. After taking an initial position on a dilemma, you were asked to rate and rank arguments that some people consider important in deciding what to do.

The arguments presented on the DIT-2 reflect different strategies or conceptual frameworks people use to explain their actions. Even though there are many kinds of arguments, research shows that, for adults, the arguments cluster into three major groups. These groups are described below:

Indexa	Index abbreviation	Reflects arguments that appeal to…
Personal interest	PI index	Personal interest and/or to maintaining one’s loyalty to family/friends
Maintaining norms	MN index	Maintaining existing laws, rules, and/or societal norms (also called “conventional arguments”)
Post-conventional	P index	Procedural justice and/or to moral principles and ideals upon which conventions, norms, rules, laws are based
Utilizer score	U score	Extent to which arguments preferred are consistent with action chosen

^aProportion of times you ranked this class of argument as most important.

Another useful index derived from the DIT-2 is the U score. The Utilizer score indicates whether you tend to apply the arguments you indicated were more important to you. Sometimes people recognize more adequate moral arguments, but do not use them in making a decision. Scores typically range from −0.5 to +0.5. A low U score indicates less consistency between the arguments selected as important, and the position that a test-taker ultimately chose.

What do these scores mean ? DIT scores do not tell you whether you are a good or kind or caring person, whether you are a law-abiding citizen, or whether you will be an excellent physician. What do tell you is something about your preferences for different conceptual frameworks—the kinds of arguments that you find appealing at this point in your life and the extent to which the arguments you chose are consistent with the action choice you chose on the measure.

One’s preference for different moral arguments tends to change as a person develops and changes. Knowing your preference helps you see whether you are likely to be in agreement with people in your profession should you be confronted with problems such as those presented on the test.

Remember also that there are other ethical abilities that are also necessary for consistent ethical actions. These include sensitivity, moral motivation and commitment, and ethical implementation abilities. The DIT-2 does not measure these abilities.

Are higher P scores better? In general, as people develop as a result of education, they tend to come to prefer postconventional arguments. The extent to which they do so varies among professions. For example, persons who devote their professional lives to working on complex moral problems, like philosophers, ethicists, and political scientists, prefer arguments based primarily upon moral principles and adherence to an underlying moral framework (postconventional moral reasoning). Accordingly they tend to have a higher P Index (mean of 65) than do persons in other walks of life, including physicians. As a group, physicians tend to have somewhat lower P scores, with proportionally higher MN scores, reflecting a greater emphasis on maintaining societal norms and rules; the average medical student selects postconventional arguments about 50 % of the time. The average adult selects postconventional arguments 40 % of the time.

What if my P Index is below the mean of my group ? Research shows that as we expand our thinking as the result of higher and professional education, our relative preference for post-conventional moral arguments increases. While we do have data correlating “P-score” (preference for postconventional thinking) with clinical performance measures and lower likelihood of malpractice judgments, we do not know whether higher scores cause these correlations. It is likely that preference for postconventional thinking equips physicians to resolve morally complex dilemmas when faced with rules/laws/norms that are ambiguous, contradictory, nonexistent, or inappropriate. As a result, the person takes a broader range of perspectives into account when making a decision about what to do.

If you got a low score on the P Index, you probably got a higher than average score on the MN Index, indicating that, as you responded to the cases, you placed a higher emphasis on adhering to explicit rules and laws than to adhering to an independent underlying moral framework.

What if I got a high MN or PI score? We all use personal interest arguments some of the time and maintaining norms arguments much of the time. There is nothing wrong with doing so UNLESS doing so disadvantages someone in a way that is fundamentally unfair. The challenge seems to be to figure out when reliance on personal interest argument or on maintaining norms does not meet the situation’s needs (when a postconventional framework is needed). The ability to distinguish among different kinds of moral arguments and to use arguments based on professional values and ideals (those which underlie rules, laws, guidelines) can be improved by rigorous discussion of complex moral dilemmas; ELSIM (first year) and Bioethics at the Bedside (third year) include such discussions.

What does the U score mean? The U score indicates the degree of consistency between the preferred arguments and the preferred action choice. If you are inconsistent, it may say that you are not sure why you picked the action you did or that you had a reason other than one of the preferred arguments. Or it may mean that you are open to reconsidering your judgment, a mark of moral maturity.

How will these results be used in this course? There is no passing or failing score on the DIT-2.⁶ We use this measure as a way to help you reflect on your approach to moral judgment and reasoning, one of several areas covered in your education on ethics and professionalism. Your specific scores will not be shared as such with anyone. De-identified results may be pooled across the class and incorporated in reports that evaluate the curriculum. If you would like to discuss your specific results or the DIT-2 in general, please contact the course director.

		Individual DIT-2 results
Student: ________________		Date DIT completed:________________
Index	Index abbreviation	Reflects arguments that appeal to…	Your individual scorea	Mean score (±s.d.) [entire class or cohort] n=
Personal interest	PI index	Personal interest and/or to maintaining one’s loyalty to family/friends
Maintaining norms	MN index	Maintaining existing laws, rules, and/or societal norms (also called “conventional arguments”)
Postconventional	P index	Procedural justice and/or to moral principles and ideals upon which conventions, norms, rules, laws are based
Utilizer score	U score	Extent to which arguments preferred are consistent with action chosen

^aProportion of times you ranked this class of argument as most important

Appendix B

1.1 Professional Identity Essay

Please print your Name and today’s date on the front of your BlueBook.

This essay explores how you understand the meaning of professionalism at this point in your development and how that relates to the formation of an ethical professional identity. Research suggests that the meaning of professionalism and one’s identity with the profession evolves throughout one’s career. Respond as fully as you can to each of the questions. In subsequent sessions you will have an opportunity to compare your responses with responses of persons contemplating becoming professionals, as well as with persons in later stages of professional development. The purpose is to engage you in self-assessment, reflection and goal setting.

Please answer these questions as fully as time allows. Write at least a paragraph for each question. Print clearly in the BlueBook provided and number each response .

• 1. What does being a member of the medical profession mean to you? How did you come to this understanding?

• 2. What do you expect of yourself as you work towards becoming a full-fledged physician?

• 3. What will patents expect of you?

• 4. What will the profession expect of you? How did you come to this understanding?

• 5. What conflicts do you experience or expect to experience between your responsibility to yourself and others—patients, family, profession? How do you resolve them?

• 6. What would be the worst thing for you if you failed to live up to the expectations you have set for yourself?

• 7. What would be the worst thing for you if you failed to live up to the expectations of your patients?

• 8. What would be the worst thing for you if you failed to live up to what society expects of physicians? How did you come to this understanding?

• 9. Think of a physician you consider an exemplar of professionalism. Describe why you chose this person, illustrating with an incident or pattern of decisions or actions that supports your choice.

Appendix C

1.1 The Evolving Professional Identity

1.1.1 Expectations and Obligations of the Professional

• To acquire the knowledge of the profession to the standards set by the profession.

• To keep abreast of changing knowledge through continuing education.

• To make a commitment to the basic ethic of the profession—that is, to place the interests of the patient above the interests of the professional, and to place the health interests of society above the interests of the profession.

• To abide by the profession’s code of ethics, or to work to change it, if it is inconsistent with the underlying ethic of the profession.

• To serve society (i.e., the public as a whole)—not just those who can pay for services.

• To participate in the monitoring and self-regulation of the profession. There are at least three dimensions to this expectation: to monitor one’s own practice to assure that processes and procedures meet ever-evolving professional standards, to report incompetent or impaired professionals, and to join one’s professional associations, in order to participate in the setting of standards for the continuation of the profession. The latter is not a legal, but rather an ethical responsibility.

1.1.2 The Evolving Professional Identity

Robert Kegan [17] suggests that all human beings are continuously involved in a process of constructing meaning. As individuals gain an increasing amount of experience in an extremely complex world, they construct progressively more complex systems for making sense of it. Similarly, each person constructs an understanding of what it means to be a professional, and a professional’s understanding may be qualitatively different from that of the general public.

Kegan’s five levels of identity transformation were adapted for the professions by Bebeau and Lewis [5] to enable educators to coach professional students, as they reflect on their evolving professional identity. Three levels of identity formation are typically evident among aspiring professionals.

1.1.2.1 The Independent Operator

These individuals look at themselves and the world in terms of individual interests and concrete, black-and-white role expectations (their own, others’, their employer’s, etc.). Personal success is paramount. It is measured by concretely accomplishing individually valued goals and enacting specific role behaviors. The perspectives of others may be overlooked, misunderstood, or misconstrued by these individuals.

How the typical Independent Operator understands professionalism. These individuals understand professionalism as meeting fixed, concrete, black-and-white role expectations, rather than a broader understanding of what it means to be a professional. Motivation for meeting standards is wholly individual and based on a desire to be correct and effective. Said one aspiring professional, “There are professional guidelines and codes that shape your life.”

1.1.2.2 The Team-Oriented Idealist

Unlike Independent Operators who view themselves and others as individuals, each with his or her own agendas and interests, Team-Oriented Idealists view themselves and others as having shared interconnections. Their capacity to make sense of the world, by taking multiple perspectives simultaneously, profoundly changes their sense of self and how they understand social reality—as shared experiences, psychological membership, and the internalization of social expectations and societal ideals. While Team-Oriented Idealists still possess and can articulate individual interests and specific behavioral goals, individual interests are no longer central.

How the Team - Oriented Idealist understands professionalism. Unlike Independent Operators, these professionals are both idealistic and internally self-reflective. They understand and identify with (or worry that they are not yet fully identified with) their chosen profession. They no longer see professionalism as enacting specific behaviors or fixed roles (the Independent Operator’s view). Rather, the Team-Oriented Idealist sees professionalism as meeting the expectations of those who are more knowledgeable and legitimate, and even more professional. As one professional remarked, “We must always hold ourselves to the highest expectations of society.” Because their identity is grounded in others, and particularly external authorities, the Team-Oriented Idealist is vulnerable to “going along with others” for the sake of “getting along,” and can have difficulty seeing boundaries between self and other.

1.1.2.3 The Integrated Professional.

If a Team-Oriented Idealist is characterized by embeddedness in and identification with a set of shared or collective identities, the Integrated Professional forges a personal system of values and internal processes for evaluating those shared identities. Team-Oriented Idealists often find themselves torn among multiple shared identities (e.g., physician, parent, spouse) with no easy way of coordinating them. As one’s responsibilities multiply, life as a Team-Oriented Idealist often becomes one of constantly trying to balance the felt obligations of multiple identities. The self-system of the Integrated Professional provides an internal compass for negotiating and resolving tensions among these multiple, shared expectations. Conflicts among the inevitable competing pulls of various roles and their attendant obligations are negotiated by adherence to one’s own internal standards and values.

How the Integrated individual understands professionalism. These individuals, unlike Team-Oriented Idealists, are no longer identified solely with external expectations of their professional role. Instead, having freely committed themselves to being a member of the profession, they have constructed a self-system comprising personal values integrated with those of the profession. These provide principles for living. While their identity is not wholly embedded in their profession, they have created a vision of the “good” profession that is grounded in reflective professional practice. As Integrated individuals continue to transition to the next level ([17] Humanist or [28] Moral Exemplar), they are able to stand aside from their own profession and even look across professions. They critically assess aspects of the professions, yet remain strongly committed. They are authentic persons who may emerge as leaders within the profession. Thus, Integrated individuals often become change agents within their profession.

In the lifelong process of identity development, individuals spend a considerable amount of time (typically many months) in the transition between stages. Transitions are characterized by the process of encompassing one’s current way of making meaning within the broader and more complex framework of the next developmental stage. Both stages may be demonstrated, with the higher stage expressed in a tentative and less well-articulated manner. Research suggests that many college-age students are in the transition between the Independent Operator and the Team-Oriented Idealist, whereas the transition between the Team-Oriented Idealist and the Integrated Professional is more typical of early to mid-career professionals. Rarely is full transformation to the Integrated Professional evident before mid-career.

Appendix D

1.1 Professional Expectations: Self-assessment and Reflection

Review the Professional Identity Essay (PIE) you wrote during the previous session and the personal statement from your residency application, to see which ideas were already a part of your understanding and what new insights you gained from the readings and lecture. Then answer the following questions in the time allowed during this session.

Please print legibly.

Name______________________ Date: ______________________

• 1. Acquire the knowledge base.

  • To what standard?

  • As you prepare to graduate, have you met the standard for acquiring a knowledge base? What else is required?

  • Was this idea part of your initial understanding as expressed in your PIE and/or Personal Statement? If not, what new insight have you gained?

• 2. Keep abreast of evolving knowledge.

  • How is this accomplished in professional life? What are some examples?

  • Was this idea part of your initial understanding? If not, what new insight have you gained?

• 3. Commit to the profession’s ethic, which is … (Be sure you are able to express this in your essay)

  • What is the profession’s ethic? (By “profession’s ethic,” we mean the basic, fundamental promise of the profession, both to individuals and society).

  • Is commitment to the profession’s ethic a matter of choice?

  • Does the profession have a right to expect that persons who join the profession will commit to the profession’s ethic? Why or why not?

  • Was this idea part of your initial understanding as expressed in your PIE and/or Personal Statement? If not, what new insight have you gained?

• 4. Abide by the code, unless …

  • Are there any circumstances under which one would not obey the code (e.g., expectations as formulated in the AMA’s Code of Ethics, the American College of Physicians’ Ethics Manual, or statements of ethical expectations from other professional societies)? What are some examples?

  • What is the difference between these sorts of codes/statements and the “ethic” of the profession?

  • What other rules or laws apply to the practice of medicine?

  • Are there different consequences for violation of the various laws and ethical codes?

  • Was this idea part of your initial understanding as expressed in your PIE and/or Personal Statement? If not, what new insight have you gained?

• 5. Serve society.

  • What is meant by “service to society?” What is the basis of society’s expectations of professionals?

  • What are the limits on those expectations?

  • What is meant by the term “pro bono” as used in some professions? How does that relate to medicine?

  • What are examples of ways (in addition to serving those who pay) that physicians can “serve society”?

  • Was this idea part of your initial understanding as expressed in your PIE and/or Personal Statement? If not, what new insight have you gained?

• 6. Regulate yourself and participate in monitoring your profession.

  • What are some examples of self-monitoring or self-regulation?

  • What is expected of each professional with respect to monitoring the profession?

  • If it isn’t legally required, why would professionals join their professional associations?

  • What three elements are required to meet this responsibility?

  • Were these elements part of your initial understanding as expressed in your PIE and/or Personal Statement? If not, what new insight have you gained?

For your reference, here are the expectations and obligations of the professional.

• To acquire the knowledge of the profession to the standards set by the profession.

• To keep abreast of changing knowledge through continuing education.

• To make a commitment to the basic ethic of the profession—that is, to place the interests of the patient above the interests of the professional, and to place the health interests of society above the interests of the profession.

• To abide by the profession’s code of ethics, or to work to change it, if it is inconsistent with the underlying ethic of the profession.

• To serve society (i.e., the public as a whole)—not just those who can pay for services.

• To participate in the monitoring and self-regulation of the profession. There are at least three dimensions to this expectation: to monitor one’s own practice to assure that processes and procedures meet ever-evolving professional standards, to report incompetent or impaired professionals, and to join one’s professional associations, in order to participate in the setting of standards for the continuation of the profession. The latter is not a legal, but rather an ethical responsibility.

Appendix E

1.1 Develop a Learning Plan for Your Professional Ethical Development

Directions: Please prepare a three- to five-page typed, double-spaced summary that reflects your assessment of your professional ethical development and your plans to enhance your development with respect to (1) professional identity formation and (2) ethical reasoning and judgment. This final, capstone assignment is the most important assignment. It gives you the opportunity to synthesize what you have learned through lecture, the assessments, and the writing exercises, to understand your strengths and challenges, and to develop a plan for developing into an exemplary professional.

• 1. Professional Identity Formation

  Review the various documents in your portfolio—your Professional Identity Essay, your Self-assessment of that essay and feedback from the instructors, your response (and revisions) to the Kramer exercise, your responses to Professional Expectations : Self Assessment and Reflection. Reflect also on the lectures and small group discussion, designed to enhance your understanding of what society expects of its professionals.

  Summarize the new insights you have developed about what is expected of you as a future medical professional. Include challenges you see yourself as facing as you begin to understand and meet professional and societal expectations.

  Then study Kegan’s descriptions as discussed in the Evolving Professional Identity and the examples you were given that illustrate the stages and transition phases. In writing:

  • (a) Rate your level of identity formation. Support your judgment with statements from documents you have written (i.e., entries in your portfolio). Be sure to cite yourself, indicating which documents you are citing

  • (b) Using the descriptions of the evolving professional identity, describe an area you believe you need to further develop. Indicate what you will do to enhance your development in this area. In addition, describe and specify the resources that you would use to aid you in this development (e.g., research and tell us what specific books, educational resources, etc., that you would use)

• 2. Ethical Reasoning and Judgment

  Summarize what you learned about the strategies you use when approaching complex social problems like those on the Defining Issues Test. What do the results tell you about your strategies compared with others in the profession? How did your group’s scores compare with yours? What did you learn about your strategies?

  Then, reflect on the lecture notes, the readings, the Landry case discussion, and your analysis/revised analysis of it. What do you think you need to do to enhance your reasoning ability? How will you accomplish this?

1.2 Handing in the Assignment

This assignment is due one week after the completion of your course. Assignment should be emailed to the course instructor. The document should be typed as a Word document and double-spaced; please label the file with your last name. You are responsible for making sure that the assignment is received; an email acknowledging receipt of your assignment will be sent.

Appendix F

1.1 Learning Plan Grading Rubric

Name______________________ Identity Formation

• 1. Summarizes new insights [NOTE: Possible to check both 1 and 2]

  • ——— Shows a willingness to cite personal shortcomings in earlier understanding of expectations

  • ——— Explains (in depth) new insights developed and cites sources of earlier understandings

  • ——— Explains some insights in a general way, without particular examples

  • ——— Simply repeats expectations as presented in class

  • — Does not summarize insights

• 2. Discusses challenges [NOTE: Possible to check both 1 and 2]

  • ——— Challenges described flow from description of insights gained

  • ——— Challenges described reflect an understanding of personal strengths and shortcomings

  • ——— Does not list challenges with respect to the expectations of a professional

• 3. Rates level of identity formation

  • ——— Rating is described in terms of Kegan’s descriptions of the Evolving Professional Identity

  • ——— Does not rate level of identity

  • ——— Rating illustrates misunderstanding of the task

• 4. Accuracy of rating of level of identity

  • ——— Consistent with professor’s judgment

  • ——— Overestimates

  • ——— Underestimates

• 5. Supports rating with evidence from portfolio entries

  • ——— Shows exceptional insight in supporting the judgment

  • ——— Shows good support for judgment

  • ——— Offers support for judgment

  • ——— Does not support judgment with evidence

• 6. Has a plan for developing his/her professional identity

  • ——— Plan reflects personal research on possible options for enhancing abilities

  • ——— Lists what he/she will do in a general way

  • ——— Doesn’t describe a plan

1.1.1 Ethical Reasoning and Judgment

• 7. Summarizes individual DIT results

  • ——— Summary reflects understanding of the data

  • ——— Summary reflects misunderstanding of the data

  • ——— Does not fully summarize DIT results

• 8. Describes individual performance in comparison with others ’ ratings

  • ——— Compares self with others’ ratings

  • ——— Comparative judgments not included

• 9. Describes individual performance in comparison with group / consensus performance

  • ——— Compares self with others’ ratings

  • ——— Comparative judgments not included

• 10. Provides data - based assessment of his/her strengths and shortcomings in terms of ethical reasoning

  • ——— Assessment reflects insight about personal strengths and shortcomings

  • ——— Assessment reflects some understanding of the data

  • ——— Assessment reflects misunderstanding of the data

  • ——— Does not provide data-based assessment

• 11. Has a plan for enhancing reasoning development

  • ——— Plan reflects personal research on possible options for enhancing abilities

  • ——— Lists what he/she will do in a general way

  • ——— Doesn’t describe a plan

1.2 Writing

1.2.1 Mechanics

——— Observes rules of grammar, spelling, and sentence structure

——— Minor errors are observed

——— Numerous errors are observed

1.2.2 Length

——— Appropriate length

——— Could be edited for length without compromising content

1.3 Other

Reflects on his/her involvement and choices in the cheating scandal?

——— Explicitly reflects on involvement, examines what defenses or lack of capacities were involved, reflects on relevance to his/her professional identity.

——— Mentions his/her involvement but does not reflect on it extensively

——— No significant explicit mention

1.4 Summary Judgment

——— Exceptional Essay (Honors)

——— Very Good Essay (High Pass)

——— Good Essay (Pass)

——— Did the assignment to minimally acceptable standards (Pass)

——— Did not complete satisfactorily (Fail)

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