Adverse Childhood Experiences in Trainees and Physicians With Professionalism Lapses: Implications for Medical Education and Remediation.

PURPOSE: Unprofessional behavior, which can include failure to engage, dishonest and/or disrespectful behavior, and poor self-awareness, can be demonstrated by medical trainees and practicing physicians. In the authors' experience, these types of behaviors are associated with exposure to adverse childhood experiences (ACEs). Given this overlap, the authors studied the percentage of ACEs among trainees and physicians referred for fitness-for-duty evaluations and patterns between the types of ACEs experienced and the reason for referral. METHOD: A final sample of 123 cases of U.S. trainees and physicians who had been referred to a Midwestern center for assessment and/or remediation of professionalism issues from 2013 to 2018 was created. Included professionalism lapses fell within 3 categories: boundary violation, disruptive behavior, or potential substance use disorder concerns. All participants completed a psychosocial developmental interview, which includes questions about ACE exposure. Overall rate of reported ACEs and types of ACEs reported were explored. RESULTS: Eighty-six (70%) participants reported at least 1 ACE, while 27 (22%) reported 4 or more. Compared with national data, these results show significantly higher occurrence rates of 1 or more ACEs and a lower occurrence rate of 0 ACEs. ACEs that predicted reasons for referral were physical or sexual abuse, feeling unwanted or unloved, witnessing abuse of their mother or stepmother, or caretaker substance use. CONCLUSIONS: In this sample, ACE exposure was associated with professionalism issues. Remediating individuals with professionalism issues and exposure to ACEs can be complicated by heightened responses to stressful stimuli, difficulties with collaboration and trust, and decreased self-efficacy. Adoption of a trauma-informed medical education approach may help those that have been impacted by trauma rebuild a sense of control and empowerment. The findings of this study may be useful predictors in identifying those at risk of problematic behavior and recidivism before a sentinel event.

Assessment of fitness for duty of underperforming physicians: The importance of using appropriate norms.

OBJECTIVE: To determine whether population-specific normative data should be employed when screening neurocognitive functioning as part of physician fitness for duty evaluations. If so, to provide such norms based on the evidence currently available. METHODS: A comparison of published data from four sources was analyzed. Data from the two physician samples were then entered into a meta-analysis to obtain full information estimates and generate provisional norms for physicians. RESULTS: Two-way analysis of variance (Study x Index) revealed a significant main effect and an interaction. Results indicate differences in mean levels of performance and standard deviation for physicians. CONCLUSIONS: Reliance on general population normative data results in under-identification of potential neuropsychological difficulties. Population specific normative data are needed to effectively evaluate practicing physicians.

Physician health and wellbeing provide challenges to patient safety and outcome quality across the careerspan.

OBJECTIVE: Age correlated changes in mental and physical capacity have contributed to increasing concerns about older physicians' clinical competence. This paper explores the relationship between age and health in a clinical population referred for fitness for duty evaluations. METHODS: Fifty cases from an evaluation center performing fitness for duty evaluations were randomly selected. Cases were reviewed for referral reason, demographic information, diagnosis, and recommendations. RESULTS: Age ranged from 28-70 (median age of 51, mode of 45).Eighty-eight percent of cases had a diagnosed medical condition with potential cognitive sequellae. CONCLUSION: While the literature supports performance concerns in aging practitioners, health independent of age, appears to be an important contributing factor. A screening process considering biopsychosocial reserve and professional load while applicable to older clinicians would optimally be implemented for physicians across their careerspan.