Professionalism in Medicine

By Deborah Cho

As an update to my previous post here on medical students and professionalism, Judge Sutton writing for the Sixth Circuit found that a medical school could deny a degree to a medical student for failing to meet “professionalism” requirements.  According to the opinion, the medical student had come late to classroom sessions, allegedly behaved inappropriately at a formal dance, had to repeat his internal medicine rotation due to poor performance, and had been convicted of driving white intoxicated.  The Sixth Circuit found that Ohio, where the medical school is located, treats the relationship between a university and a student as contractual in nature, with that contract’s terms supplied by the student handbook.  As the handbook in this case included professionalism as part of the academic curriculum, the university’s determination that the student failed to meet professionalism requirements was an academic judgment and thus merited deference by the court.

Last summer, Judge Gwin of the Northern District of Ohio found that the medical school went beyond its scope of duty by extending its determination of professionalism well past academic or patient related matters.  The district court found for the student, noting that the “character judgments” found by the university were “only distantly related to medical education.”  In my last post, I noted that this separation of personal character from competence to practice medicine seemed troublesome.  The Sixth Circuit’s opinion reversing the district court shows similar concerns.

Judge Sutton states early in the opinion, “Anyone who has ever been to a doctor’s office knows the value of a good bedside manner.”  He continues, “[The school’s] curriculum identifies nine ‘core competencies.’  First on the list is professionalism.  Medical knowledge does not make an appearance until the fifth slot.”  He also notes that “[p]rofessionalism has been a part of the doctor’s role since at least ancient Greece” and cites to the Hippocratic Oath.  Implicit is the idea that professionalism – which here includes ethical, honest, responsible, reliable, and respectful behavior without inappropriate personal biases – is possibly more important than competence in medical practice.  This belief seems to be mirrored by patients in at least one survey, and is an idea that I can understand, if not fully support.

The deference applied to the university’s decision after an apparent lack of process, however, is disconcerting.  On one hand, the court defers to the medical school’s determination because it is an “academic determination” made by a university.  On the other hand, the court highlights that the unique character of medical practice requires the consideration of professionalism, such as by alluding to the importance of bedside manner.  The court also states, “That many professionalism-related cases involve classroom incidents does not establish that only classroom incidents are relevant to the professionalism inquiry . . . Our own standards indicate that professionalism does not end at the courtroom door.  Why should hospitals operate any differently?” (citations omitted).  But the court is not reviewing a case of a hospital withdrawing admitting privileges from a doctor nor of a board of medicine revoking a medical license.  Those acts of self-regulation by the medical profession typically involve procedural and evidentiary hurdles that warrant a deferential standard of review by reviewing courts (see here and here).  Instead, the court is reviewing a university’s academic determination.

Here, the university’s Committee on Students made a determination of a non-academic nature while appearing to apply the process for academic determinations.  The Committee nonetheless received deference because the professionalism requirement was included in the student handbook and because it is an essential characteristic of being a doctor.  The court concluded, “[the student] claims that the Committee faulted him for things that didn’t happen (for instance, the sexual harassment incidents at the Hippo Ball) and disregarded his explanations for the things that did (for instance, his poor internship performance and his driving-while-intoxicated conviction).  He invites us to decide for ourselves whether he behaved in a sufficiently professional way to merit a degree.  That, as we have made clear, goes beyond our job description.  It was neither arbitrary nor capricious for the Committee to credit other accounts above [the student’s.]”

Although I initially disagreed with the district court’s decision stating that professionalism was only distantly related to patient care, considering the application of the Sixth Circuit’s holding is worrying.  I question if the Sixth Circuit’s decision allows for medical schools to deny medical degrees to students whom they determine to be of unsatisfactory moral character based on the loosest criteria.  If so, are we allowing medical schools to hold our future doctors to impossible standards or, even worse, subjecting them to the personal biases of administrators?

(As an aside, I wonder if this decision and the authority cited have any implications for non-medical academic institutions that wish to enforce certain moral or ethical standards through professionalism requirements.  It is not difficult imagine that professionalism is necessary for just about every profession that interacts with other human beings.  Furthermore, can an institution refuse to grant a degree to an individual based on unsubstantiated sexual harassment claims that show a lack of professionalism and thereby circumvent Title IX procedural requirements?)

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