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In a first-of-its-kind study, researchers at Jefferson Medical College in Philadelphia have found that doctors who are disciplined by  state medical boards, were three times as likely as their colleagues to have exhibited unprofessional behavior in medical school. Investigators who conducted this national inquiry say it reinforces the need to stress the vital importance of professionalism from the time a student enters medical school all the way through his or her professional career.

Published this week in The New England Journal of Medicine, the study is the work of a team of researchers including Susan Rattner, M.D., and J. Jon Veloski, MS, both of Thomas Jefferson University. The effort was led by Maxine Papadakis, M.D., of the University of California‑San Francisco School of Medicine.

“Unprofessional behavior among students was defined as including irresponsibility, diminished capacity for self-improvement, poor initiative and impaired interpersonal relationships,” said Dr. Rattner, clinical associate professor of Medicine and Senior Associate Dean for Undergraduate Medical Education at Jefferson.

These students were nearly nine times more likely than their colleagues to be disciplined when they became practicing physicians.

Emphasizing that this is “a rare problem  affecting only a very small group of practicing physicians,” Dr. Rattner nonetheless concluded that “because professionalism is a fundamental core value in the practice of medicine, it must be taught and modeled in all of our educational and clinical activities.  It is imperative that technical standards for admission to medical school and outcome objectives for graduation address professional behavior.”

The study recommends  standardized methods be implemented for both assessing the personal qualities of medical school applicants and predicting their performance as doctors.

“Recent objectives for undergraduate and graduate medical education include professionalism in their core competency,” Dr. Rattner said. “Our study lends support for its inclusion and provides specific examples of unprofessional behavior.”

Study co-author Jon Veloski, Director of Research Medical Education at Jefferson’s Center for Research in Medical Education and Health Care, affirmed that disciplinary action by state boards is rare; the overall rate of disciplinary action found in the study was less than 0.2 percent per year. Nationally it is only about 0.3 percent. “During the lifetime of a professional practice,” he said, “the number of disciplined physicians is very small compared to the total population of practicing physicians.”

The study includes the University of California-San Francisco School of Medicine, Jefferson Medical College, and the University of Michigan Medical School in Ann Arbor and includes 235 doctors who graduated since 1970.

“These three schools were selected because they are geographically diverse, represent both public and private institutions and have very thorough records of their own students,” said Veloski.

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.

“It is hoped that the current emphasis on more objective measures of professionalism in both medical school and residency training is supported by this important study. Identification and remediation of deficiencies in professional behavior at a formative stage in a physician’s development brings the promise of reduced episodes of professional lapses in practice,” stated Thomas J. Nasca, M.D, MACP, Dean of Jefferson Medical College.

“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, M.D., president and CEO of the Federation of State Medical Boards (FSMB). Co-authors of the study include Timothy R. Knettler, MBA, of FSMB, Arianne Teherani, Ph.D, and Mary A. Banach, Ph.D, MPH, of UCSF; David T. Stern, M.D., Ph.D, of UM Medical School and Veterans Affairs Ann Arbor Healthcare System; and Carol S. Hodgson, Ph.D, 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, M.D., Medical Education Research Fund of the National Board of Medical Examiners.