Holly J. Humphrey, MD

Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.

A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]

Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.

We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.

METHODS

A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.

Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.

A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.

Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.

RESULTS

Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).

The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).

Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.

CONCLUSIONS

Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]

Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]

There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.

Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.

Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.

Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.

A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]

Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.

We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.

METHODS

A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.

Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.

A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.

Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.

RESULTS

Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).

The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).

Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.

CONCLUSIONS

Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]

Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]

There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.

Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.

Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.

Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.

A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]

Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.

We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.

METHODS

A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.

Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.

A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.

Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.

RESULTS

Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).

The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).

Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.

CONCLUSIONS

Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]

Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]

There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.

Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.

Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.

The discrepancy between what is taught about professionalism in formal medical education and what is witnessed in the hospital has received increasing attention.17 This latter aspect of medical education contributes to the hidden curriculum and impacts medical trainees' views on professionalism.8 The hidden curriculum refers to the lessons trainees learn through informal interactions within the multilayered educational learning environment.9 A growing body of work examines how the hidden curriculum and disruptive physicians impact the learning environment.9, 10 In response, regulatory agencies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), require training programs and medical schools to maintain standards of professionalism, and to regularly evaluate the learning environment and its impact on professionalism.11, 12 The ACGME in 2011 expanded its standards regarding professionalism by making certain that the program director and institution ensure a culture of professionalism that supports patient safety and personal responsibility.11 Given this increasing focus on professionalism in medical school and residency training programs, it is critical to examine faculty perceptions and actions that may perpetuate the discrepancy between the formal and hidden curriculum.13 This early exposure is especially significant because unprofessional behavior in medical school is strongly associated with later disciplinary action by a medical board.14, 15 Certain unprofessional behaviors can also compromise patient care and safety, and can detract from the hospital working environment.1618

In our previous work, we demonstrated that internal medicine interns reported increased participation in unprofessional behaviors regarding on‐call etiquette during internship.19, 20 Examples of these behaviors include refusing an admission (ie, blocking) and misrepresenting a test as urgent. Interestingly, students and residents have highlighted the powerful role of supervising faculty physicians in condoning or inhibiting such behavior. Given the increasing role of hospitalists as resident supervisors, it is important to consider the perceptions and actions of hospitalists with respect to perpetuating or hindering some unprofessional behaviors. Although hospital medicine is a relatively new specialty, many hospitalists are in frequent contact with medical trainees, perhaps because many residency programs and medical schools have a strong inpatient focus.2123 It is thus possible that hospitalists have a major influence on residents' behaviors and views of professionalism. In fact, the Society of Hospital Medicine's Core Competencies for Hospital Medicine explicitly state that hospitalists are expected to serve as a role model for professional and ethical conduct to house staff, medical students and other members of the interdisciplinary team.24

Therefore, the current study had 2 aims: first, to measure internal medicine hospitalists' perceptions of, and participation in, unprofessional behaviors using a previously validated survey; and second, to examine associations between job characteristics and participation in unprofessional behaviors.

METHODS

RESULTS

Seventy‐seven of the 101 hospitalists (76.2%) at 3 sites completed the survey. While response rates varied by site (site 1, 67%; site 2, 74%; site 3, 86%), the differences were not statistically significant (² = 2.9, P = 0.24). Most hospitalists (79.2%) completed residency after 2000. Over half (57.1%) of participants were male, and over half (61%) reported having worked with their current hospitalist group from 1 to 4 years. Almost 60% (59.7%) reported being unfamiliar with residents in the program. Over 40% of hospitalists did not do any night work. Hospitalists were largely clinical, one‐quarter of hospitalists reported working over 50% FTE, and the median was 80% FTE. While 78% of hospitalists reported some teaching time, median time on teaching service was low at 10% (Table 1).

Hospitalists perceived almost all behaviors as unprofessional (unprofessional or somewhat unprofessional on a 5‐point Likert Scale). The only behavior rated as professional with a mean of 4.25 (95% CI 4.014.49) was staying past shift limit to complete a patient‐care task that could have been signed out. This behavior also had the highest level of participation by hospitalists (81.7%). Hospitalists were most ambivalent when rating professionalism of attending an industry‐sponsored dinner or social event (mean 3.20, 95% CI 2.983.41) (Table 2).

Participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self‐perceived level of skill (2.60%), was very low. The most common behaviors rated as unprofessional that hospitalists reported participating in were having nonmedical/personal conversations in patient corridors (67.1%), ordering a routine test as urgent to expedite care (62.3%), and making fun of other physicians to colleagues (40.3%). Forty percent of participants reported disparaging the emergency room (ER) team or primary care physician for findings later discovered, signing out over the phone when it could have been done in person, and texting or using smartphones during educational conferences. In particular, participation in unprofessional behaviors related to trainees was close to zero (eg, asking a student to discuss, with patients, medical or surgical information which is perceived to be beyond their level of knowledge). The least common behaviors that hospitalists reported participating in were discharging a patient before they are ready to go home in order to reduce one's census (2.56%) and reporting patient information as normal when uncertain of the true results (2.60%). Like previous studies of unprofessional behaviors, those that reported participation were less likely to report the behavior as unprofessional.8, 19

Observation of behaviors ranged from 4% to 80%. In all cases, observation of the behavior was reported at a higher level than participation. Correlation between observation and participation was also high, with the exception of a few behaviors that had zero or near zero participation rates (ie, reporting patient information as normal when unsure of true results.)

After performing factor analysis, 4 factors had eigenvalues greater than 1 and were therefore retained and extracted for further analysis. These 4 factors accounted for 76% of the variance in responses reported on the survey. By examining which items or groups of items most strongly loaded on each factor, the factors were named accordingly: factor 1 referred to behaviors related to making fun of others, factor 2 referred to workload management, factor 3 referred to behaviors related to the learning environment, and factor 4 referred to behaviors related to time pressure (Table 3).

Using site‐adjusted multivariate regression, certain hospitalist job characteristics were associated with certain patterns of participating in unprofessional behavior (Table 4). Those with less clinical time (<50% FTE) were more likely to participate in unprofessional behaviors related to making fun of others (factor 1, value = 0.94, 95% CI 0.32 to 1.56, P value <0.05). Hospitalists who had any administrative time ( value = 0.61, 95% CI 0.111.10, P value <0.05) were more likely to report participation in behaviors related to workload management. Hospitalists engaged in any night work were more likely to report participation in unprofessional behaviors related to time pressure ( value = 0.67, 95% CI 0.171.17, P value <0.05). Time devoted to teaching or research was not associated with greater participation in any of the domains of unprofessional behavior surveyed.

The only demographic characteristic that was significantly associated with unprofessional behavior was age. Specifically, those who were born after 1970 were more likely to participate in unprofessional behaviors related to workload management ( value = 0.87, 95% CI 0.071.67, P value <0.05). Site differences were also present. Specifically, one site was more likely to report participation in unprofessional behaviors related to workload management ( value site 1 = 1.01, 95% CI 0.15 to 1.86, P value <0.05), while another site was less likely to report participation in behaviors related to the learning environment ( value site 3 = 0.70, 95% CI 1.31 to 0.09, P value <0.05). Gender and familiarity with residents were not significant predictors of participation in unprofessional behaviors. Results remained robust in sensitivity analyses using different cutoffs of clinical time and teaching time.

DISCUSSION

This multisite study adds to what is known about the perceptions of, and participation in, unprofessional behaviors among internal medicine hospitalists. Hospitalists perceived almost all surveyed behaviors as unprofessional. Participation in egregious and trainee‐related unprofessional behaviors was very low. Four categories appeared to explain the variability in how hospitalists reported participation in unprofessional behaviors: making fun of others, workload management, learning environment, and time pressure. Participation in behaviors within these factors was associated with certain job characteristics, such as clinical time, administrative time, and night work, as well as age and site.

It is reassuring that participation in, and trainee‐related, unprofessional behaviors is very low, and it is noteworthy that attending an industry‐sponsored dinner is not considered unprofessional. This was surprising in the setting of increased external pressures to report and ban such interactions.28 Perception that attending such dinners is acceptable may reflect a lag between current practice and national recommendations.

It is important to explore why certain job characteristics are associated with participation in unprofessional behaviors. For example, those with less clinical time were more likely to participate in making fun of others. It may be the case that hospitalists with more clinical time may make a larger effort to develop and maintain positive relationships. Another possible explanation is that hospitalists with less clinical time are more easily influenced by those in the learning environment who make fun of others, such as residents who they are supervising for only a brief period.

For unprofessional behaviors related to workload management, those who were younger, and those with any administrative time, were more likely to participate in behaviors such as celebrating a blocked‐admission. Our prior work shows that behaviors related to workload management are more widespread in residency, and therefore younger hospitalists, who are often recent residency graduates, may be more prone to participating in these behaviors. While unproven, it is possible that those with more administrative time may have competing priorities with their administrative roles, which motivate them to more actively manage their workload, leading them to participate in workload management behaviors.

Hospitalists who did any night work were more likely to participate in unprofessional behaviors related to time pressure. This could reflect the high workloads that night hospitalists may face and the pressure they feel to wrap up work, resulting in a hasty handoff (ie, over the phone) or to defer work (ie, family questions). Site differences were also observed for participation in behaviors related to the learning environment, speaking to the importance of institutional culture.

It is worth mentioning that hospitalists who were teachers were not any less likely to report participating in certain behaviors. While 78% of hospitalists reported some level of teaching, the median reported percentage of teaching was 10% FTE. This level of teaching likely reflects the diverse nature of work in which hospitalists engage. While hospitalists spend some time working with trainees, services that are not staffed with residents (eg, uncovered services) are becoming increasingly common due to stricter resident duty hour restrictions. This may explain why 60% of hospitalists reported being unfamiliar with residents. We also used a high bar for familiarity, which we defined as knowing half of residents by name, and served as a proxy for those who may have trained at the institution where they currently work. In spite of hospitalists reporting a low fraction of their total clinical time devoted to resident services, a significant fraction of resident services were staffed by hospitalists at all sites, making them a natural target for interventions.

These results have implications for future work to assess and improve professionalism in the hospital learning environment. First, interventions to address unprofessional behaviors should focus on behaviors with the highest participation rates. Like our earlier studies of residents, participation is high in certain behaviors, such as misrepresenting a test as urgent, or disparaging the ER or primary care physician (PCP) for a missed finding.19, 20 While blocking an admission was common in our studies of residents, reported participation among hospitalists was low. Similar to a prior study of clinical year medical students at one of our sites, 1 in 5 hospitalists reported not correcting someone who mistakes a student for a physician, highlighting the role that hospitalists may have in perpetuating this behavior.8 Additionally, addressing the behaviors identified in this study, through novel curricular tools, may help to teach residents many of the interpersonal and communication skills called for in the 2011 ACGME Common Program Requirements.11 The ACGME requirements also include the expectation that faculty model how to manage their time before, during, and after clinical assignments, and recognize that transferring a patient to a rested provider is best. Given that most hospitalists believe staying past shift limit is professional, these requirements will be difficult to adopt without widespread culture change.

Moreover, interventions could be tailored to hospitalists with certain job characteristics. Interventions may be educational or systems based. An example of the former is stressing the impact of the learning and working environment on trainees, and an example of the latter is streamlining the process in which ordered tests are executed to result in a more timely completion of tests. This may result in fewer physicians misrepresenting a test as urgent in order to have the test done in a timely manner. Additionally, hospitalists with less clinical time could receive education on their impact as a role model for trainees. Hospitalists who are younger or with administrative commitments could be trained on the importance of avoiding behaviors related to workload management, such as blocking or turfing patients. Lastly, given the site differences, critical examination of institutional culture and policies is also important. With funding from the American Board of Internal Medicine (ABIM) Foundation, we are currently creating an educational intervention, targeting those behaviors that were most frequent among hospitalists and residents at our institutions to promote dialogue and critical reflection, with the hope of reducing the most prevalent behaviors encountered.

There are several limitations to this study. Despite the anonymity of the survey, participants may have inaccurately reported their participation in unprofessional behaviors due to socially desirable response. In addition, because we used factor analysis and multivariate regression models with a small sample size, item nonresponse limited the sample for regression analyses and raises the concern for response bias. However, all significant associations remained so after performing backwards stepwise elimination of covariates that were P > 0.10 in models that were larger (ranging from 65 to 69). Because we used self‐report and not direct observation of participation in unprofessional behaviors, it is not possible to validate the responses given. Future work could rely on the use of 360 degree evaluations or other methods to validate responses given by self‐report. It is also important to consider assessing whether these behaviors are associated with actual patient outcomes, such as length of stay or readmission. Some items may not always be unprofessional. For example, texting during an educational conference might be to advance care, which would not necessarily be unprofessional. The order in which the questions were asked could have led to bias. We asked about participation before perception to try to limit bias reporting in participation. Changing the order of these questions would potentially have resulted in under‐reporting participation in behaviors that one perceived to be unprofessional. This study was conducted at 3 institutions located in Chicago, limiting generalizability to institutions outside of this area. Only internal medicine hospitalists were surveyed, which also limits generalizability to other disciplines and specialties within internal medicine. Lastly, it is important to highlight that hospitalists are not the sole teachers on inpatient services, since residents encounter a variety of faculty who serve as teaching attendings. Future work should expand to other centers and other specialties.

In conclusion, in this multi‐institutional study of hospitalists, participation in egregious behaviors was low. Four factors or patterns underlie hospitalists' reports of participation in unprofessional behavior: making fun of others, learning environment, workload management, and time pressure. Job characteristics (clinical time, administrative time, night work), age, and site were all associated with different patterns of unprofessional behavior. Specifically, hospitalists with less clinical time were more likely to make fun of others. Hospitalists who were younger in age, as well as those who had any administrative work, were more likely to participate in behaviors related to workload management. Hospitalists who work nights were more likely to report behaviors related to time pressure. Interventions to promote professionalism should take institutional culture into account and should focus on behaviors with the highest participation rates. Efforts should also be made to address underlying reasons for participation in these behaviors.