Maxine A. Papadakis, MD, professor of clinical medicine at the University of California, San Francisco and associate dean of student affairs at UCSF School of Medicine, led the research team. Study findings are reported in the December 22 issue of the New England Journal of Medicine.
The researchers looked for early warning signs during medical school that were associated with a higher risk for disciplinary action when the students became practicing physicians.
Behavior for which physicians were disciplined included use of drugs or alcohol, unprofessional conduct, conviction for a crime, and negligence. Unprofessional behavior in medical school was the strongest risk factor for later disciplinary action by a state medical board. In contrast, more traditional measures of academic success, such as performance on the Medical College Admission Test and early medical school grades, were much weaker risk factors for later disciplinary action, according to the study.
Papadakis, who is also a staff physician at the San Francisco VA Medical Center, cautioned that because the study is retrospective, it is not predictive of future behavior of current medical school students. "However, we have at least established a risk factor for disciplinary action against practicing physicians," she said.
This is the first national study that links performance in medical school with later disciplinary action, and therefore with a potential threat to patient safety, according to Papadakis. "These data support the growing movement to make the demonstration of professional behavior a requirement for graduation from medical school in the United States. It is one way that we can improve health care quality by focusing on human factors that ultimately affect physician performance," she said.
"This research is an excellent example of how medical boards and medical schools can collaborate to improve patient care by quantifying available data, with the ultimate goal of improving the quality of patient care and patient safety," said James N. Thompson, MD, president and CEO of the Federation of State Medical Boards (FSMB).
The study included 235 graduates since 1970 of three medical schools - UCSF School of Medicine, University of Michigan Medical School in Ann Arbor, and Jefferson Medical College of Thomas Jefferson University in Philadelphia - who were disciplined by one of 40 state medical boards between 1990 and 2003. They were matched with 469 control physicians according to medical school and graduation year.
"We looked at these three schools because they're geographically diverse, represent both public and private institutions, and have very thorough records of their own students," said Papadakis.
The study looked at a broad range of unprofessional behaviors in medical students. The strongest association with disciplinary action was seen in students who were irresponsible in attendance or patient care. These students were nearly nine times more likely than their colleagues to be disciplined when they became practicing physicians.
"Professionalism can and must be taught in medical school," note the study authors. As part of this, the study recommends that medical school admissions and graduation standards should be reviewed to make sure they contain explicit language about professional behavior and that professionalism should be an important part of the curriculum. It also recommends that standardized methods should be implemented for both assessing the personal qualities of medical school applicants and predicting their performance.
"Most physicians take great pride in their professionalism and this is a quality that must be cherished," Papadakis said. "Our study shows that the tradition of professionalism must begin in medical school and that standards for professionalism in students are as important, or perhaps more important than other measures of success."
She stressed the importance of early identification and remediation of unprofessional behavior among medical students. "We want to identify people who have trouble in this domain as early as possible," she said. "We all grow up, and most of us become more professional as we mature. However, for the rare student who cannot demonstrate professional behavior, we need to think long and hard about whether he or she should graduate from medical school."
Papadakis noted the collaborative nature of the research, saying, "This study brings together the licensing and disciplinary branch of the medical system, represented by the Federation of State Medical Boards, with the medical schools, so that we can all help patients in the long run."
Co-authors of the study include Timothy R. Knettler, MBA, of FSMB, Arianne Teherani, PhD, and Mary A. Banach, PhD, MPH, of UCSF; Susan L. Rattner, MD, of Jefferson Medical College; David T. Stern, MD, PhD, of UM Medical School and Veterans Affairs Ann Arbor Healthcare System; Jon Veloski, MS, of JMC; and Carol S. Hodgson, PhD, of the University of Colorado at Denver and Denver Health Sciences Center.
This study was supported in part by a grant from the Edward J. Stemmler, MD Medical Education Research Fund of the National Board of Medical Examiners.
UCSF is a leading university that consistently defines health care worldwide by conducting advanced biomedical research, educating graduate students in the life sciences, and providing complex patient care.