Students who need disciplining often need it again as doctors

New research supports what some educators and medical board leaders suspected: Medical students who misbehaved became physicians who misbehaved.

In fact, the study found that physicians disciplined by state medical boards were three times more likely to have behaved unprofessionally in medical school than their colleagues.

The national rate of disciplinary action among the approximately 725,000 practicing U.S. physicians is 0.3%, according to the study in the Dec. 22, 2005, New England Journal of Medicine. But students at three medical schools who were irresponsible in areas such as patient care or attendance were about eight times more likely than colleagues to be disciplined after they became practicing physicians.

Among the violations medical boards disciplined these doctors for: drug abuse, unprofessional conduct, negligence and inappropriate prescribing. And most physicians who were disciplined committed multiple violations.

Unless professionalism is stressed more in medical school, the trend is not likely to change, medical leaders said.

"Professionalism should be interwoven into everything. It's not enough to have one lecture on it in the introduction to medical school," said lead study author Maxine Papadakis, MD, professor of clinical medicine at University of California, San Francisco, School of Medicine, and associate dean of student affairs.

Dr. Papadakis and fellow researchers studied 235 graduates of three medical schools who were disciplined by state medical boards between 1990 and 2003. The doctors were compared with 469 classmates who had not been disciplined by boards. The subjects graduated from the University of Michigan Medical School in Ann Arbor, Mich.; Jefferson Medical College of Thomas Jefferson University in Philadelphia and UCSF.

Researchers examined narratives describing unprofessional behavior, grades, standardized test scores and other material. The study showed that unprofessional behavior was a better indicator of later discipline than more traditional measures of academic success, such as Medical College Admission Test scores and poor grades early in medical school.

Steps toward professionalism

Dr. Papadakis said the study adds further evidence that some medical students need intervention to help get them on the right path. A pilot study of UCSF graduates two years ago had a similar finding that medical students who behaved unprofessionally displayed similar behavior as physicians.

"We all become more professional as we grow up, so we can turn people around," she said.

The Federation of State Medical Boards said it was working with the American Medical Association and the Assn. of American Medical Colleges to develop model curricula that medical schools would use to promote professionalism. Courses likely would include teaching students about the role of state medical boards and what it means to have a license to practice medicine, an FSMB official said.

"[The new study] should be helpful to medical schools in developing programs to assess the competencies students must have to become physicians," said FSMB President and CEO James Thompson, MD.

Professionalism in more courses

Educators and researchers both say medical schools are paying more attention to the teaching of professional behavior to students and are offering more courses dealing with professionalism.

Some schools are trying to give students more feedback about behavior and assessing students more thoroughly. Others are using peer assessments, in which students can evaluate classmates anonymously.

"There has been a very strong re-awakening of the need for professionalism," said AAMC President Jordan J. Cohen, MD.

Dr. Papadakis and others say professionalism no longer should be a secondary factor in what makes a good doctor.

"We can help improve patient quality by addressing some of these things earnestly in medical school," she said. "We can help the student, and we can help patient quality."