An Oakland University William Beaumont School of Medicine professor is first author on a new article in The New England Journal of Medicine that suggests revamping the way organizations handle medical trainee unprofessionalism.

“Responding to Unprofessional Behavior by Trainees — A ‘Just Culture’ Framework,” was written by Jason Wasserman, Ph.D., associate professor, Department of Foundational Medical Studies and Department of Pediatrics, OUWB, along with Michael Redinger, M.D., and Tyler Gibb, J.D., Ph.D., both of Western Michigan University Home Stryker M.D. School of Medicine.

In short, the paper suggests organizations repurpose the concept of a “just culture” to establish a better way of handling medical trainee unprofessionalism, and to “promote fairness in the evaluations process and consistency in the response.”

Wasserman said doing so would help organizations manage “situations that can be very messy, convoluted, and emotional”— a scenario he describes as a “common struggle.”

“The article addresses a challenge in medical education that so many people across the country can identify with,” Wasserman said. “It applies to professional academic medicine, as well as anyone who supervises residents, or takes medical students in their practice — we all struggle with how to make sense of the best ways to respond when trainees fall short of professional expectations.” 

‘Just culture’ and medical trainee unprofessionalism

Wasserman said The New England Journal of Medicine (NEJM) article centers on repurposing the notion of a “just culture” — an approach that has gained widespread use in medicine during the last two decades and proven effective in dealing with medical errors.

A “just culture” essentially recognizes that individual practitioners should not necessarily be held accountable for system failings over which they have no control and aims to provide a psychologically safe space in which errors can be discussed and addressed, so that both individuals and the system as a whole can learn and improve.

With that in mind, the article suggests that principles of “just culture” can be adapted to instances of unprofessional behavior by examining not only what happened in any particular instance, but the knowledge and intentions of the trainee, as well as factors in the practice and learning environments that contributed to the lapse.

In the adapted framework offered by the authors, lapses in professionalism range from no-fault suboptimality — a lapse caused largely by environmental factors, but that could have been handled better by the student, such as an alarm clock failing to go off after a power outage resulting in a missed mandatory class — to egregious unprofessionalism, say logging into the medical record of a family friend post-HIPAA training.

By design, Wasserman said, the system would be especially helpful with cases that are particularly ambiguous.

“When instances of unprofessionalism are egregious, it’s pretty simple — someone is accused of academic misconduct, for example, we usually know what to do with that,” he said. “But when the unprofessionalism is not that egregious but we still want to address it, (without a framework in place) it becomes less clear how to think about what happened and determine the response.”

By suggesting a practical system that can be used to address medical trainee unprofessionalism, Wasserman said the article does more than “wax philosophic” about the issue.

“It applies a structured set of questions that we can use to really work our way toward a response that both addresses the issue, but is also sensitive to the fact that trainees are, by definition, still learning and growing within the profession,” he said.

A career milestone

Wasserman said the seed of the idea can be traced back “four or five years” to when he and the other authors (Redinger and Gibb) first discussed common issues they identified in dealing with medical trainee unprofessionalism.

When the trio set out to write about the issue, it took about a year for the team to finalize the article and have it accepted by NEJM — the world’s leading medical journal that’s been published continuously for more than 200 years.

Wasserman said having the piece published in NEJM is a career milestone he set out to achieve when he was an undergraduate and took an introduction to ethics class taught by the late James Rachels at University of Alabama at Birmingham. 

Rachels wrote an article called “Active and Passive Euthanasia” that appeared in NEJM in 1975 and has played a major role in debates about physician assisted suicide.

“I heard that story and read that article when I was 18 years old, and ever since, publishing in The New England Journal of Medicine has been a career milestone that I had hoped to achieve one day,” said Wasserman.

Among other reasons, he said, is the fact that the publication has an impact factor of 70 – the highest of all medical journals. (The impact factor reflects the yearly average number of citations received by articles in a given journal and published in the last two years.)

Additionally, according to the NEJM website, more than 600,000 people read NEJM weekly in print and online.

“It is a privilege to have a colleague like Jason in the department,” said Doug Gould, Ph.D., professor of neuroscience and chair of the Department of Foundational Medical Studies.

“He has been one of our most successful scholars for many years and it is an exceptional recognition of his work to have a publication in the very best medical journal,” said Gould. “I am confident that Jason’s achievement is a tangible sign of the accelerating upward trajectory of the department as a whole.”

For more information, contact Andrew Dietderich, marketing writer, OUWB, at [email protected]. 

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