One of four Featured Plenaries at the 2025 ACGME Annual Educational Conference, “Remediation of Professionalism Issues in Residency” addressed one of the most challenging aspects faced by program directors: dealing with professionalism lapses and deficiencies in residents. Led by Kathryn Hughs, MD, a pulmonology and critical care fellow at Naval Medical Center San Diego; Elexis McBee, DO, MPH, FACP, an associate professor of Medicine at the Uniformed Services University; Biraj D. Shah, MD, FACP, the internal medicine program director at Scripps Clinic/Scripps Green Hospital; and Mark Tschanz, DO, MACM, FACP, the designated institutional official at Naval Medical Center Portsmouth, the session provided valuable insights and strategies for effectively managing and remediating professionalism issues within graduate medical education (GME) programs.
Understanding Professionalism and its Challenges
The session began with a comprehensive overview of professionalism, its definitions, and the expectations set by the ACGME. Dr. McBee emphasized the importance of understanding the ACGME Core Competency of Professionalism, and common lapses that occur during residency. “Professionalism is not just about adhering to ethical standards,” she said, “it's about internalizing the values and norms that define our profession.”
The presenters highlighted the historical context for professionalism in American medicine, tracing its evolution from the first Code of Ethics of the American Medical Association in 1847, to its inclusion as an ACGME Core Competency in 1999. This historical perspective provided a foundation for understanding the current challenges and the need for effective remediation strategies.
Common Professionalism Lapses and Remediation Strategies
The session delved into the common lapses in professionalism observed in residency programs, including failure to engage, disrespectful behaviors, dishonest behaviors, and poor self-awareness. “Gathering additional information is a good place to start, which includes a conversation with the resident,” shared Dr. Shah. She encouraged attendees to “be responsive and not reactive… [to] aim to be fair, consistent, and non-judgmental… [and to] be curious.”
The presenters discussed various remediation strategies, emphasizing the importance of documentation, formal counseling, and the use of professionalism contracts. Dr. Tschanz highlighted the significance of a collaborative approach, stating, “A collaborative approach in coming up with remediation plans is always best. Give the resident the opportunity to share what they could do to meet the milestone.”
The Remediation Continuum
A key focus of the session was the remediation continuum, a three-step process designed to address professionalism lapses effectively. The steps include internal remediation, formal counseling, and academic probation. Each step includes specific actions and documentation to ensure a fair and consistent approach:
- Step 1: Internal Remediation. Internal remediation involves addressing the professionalism lapse within the program. This step includes gathering information, having conversations with the resident, and documenting the issue. If the concern persists or escalates, the process moves to the next step.
- Step 2: Formal Counseling. Formal counseling is initiated for egregious or repeat violations. This involves more structured interventions, including formal meetings and documentation. The goal is to provide the resident with clear expectations and support to address the professionalism lapse.
- Step 3: Academic Probation. Academic probation is the final step in the remediation continuum. It is used for severe or persistent professionalism issues and always includes counseling. Probation must be reported and goes on the resident's permanent record. Dr. Tschanz emphasized that, “The benefit of academic probation is that you have institutional resources to support the program and the resident to… improve.”
Case Studies and Interactive Discussions
The session also included interactive case studies that demonstrated the application of the remediation continuum in real-life scenarios. Attendees participated in discussions and polls, providing their insights and experiences. One case study highlighted the challenges of navigating conflicting professional identities, with residents bringing pre-existing identities, such as a leadership role with complete autonomy, into their professional roles. Dr. McBee encouraged attendees to consider these conflicts, stating, “I want us to think about past identities and how they conflict with professional identity. Our job is how to integrate these professional identities.”
Another case study focused on the importance of mentoring and support for residents undergoing remediation. Dr. Hughs recommended a strategic approach to mentoring, suggesting, “Be strategic about mentoring. Let the resident choose a mentor off a curated list. Mandate the mentor meetings, ensure they are meeting regularly.”
Conclusion and Key Takeaways
The session concluded with a summary of key takeaways and recommendations for program directors and educators. The presenters emphasized the importance of a comprehensive evaluation program, clear documentation, and a supportive approach to remediation. They also highlighted the need for institutional policies that ensure due process and fairness in addressing professionalism lapses.