Creating a framework for the remediation of unprofessional behaviour in medical students

There is a recognised association between professionalism lapses at medical school and later professional misconduct. Medical educators and regulators have increasingly called for professionalism lapses to be identified and addressed at medical school to prevent future problems. Many approaches to remediation have been reported; however, there is a lack of empirical or theoretical basis to many approaches and there are few reports of successful remediation models, particularly over the medium- and long-term. Indeed, in this research, medical schools in the United Kingdom identified that remediation of professionalism lapses is a resourceintensive process but outcomes are uncertain. One of the challenges of addressing unprofessional behaviour is the lack of a consistent definition of professionalism. Many existing definitions rely on an inequitable perception of a 'professional' doctor that has not evolved to reflect the diversity of the profession. With this in mind, 'unprofessional behaviour' may in fact represent diverse ways of being a medical student that do not align with out-dated professional norms and expectations. Increasingly, medical students are understood to learn professionalism through a process of identity development. Using a qualitative narrative methodology, this research explored the identities that 'unprofessional' students learn and perform. Analysis of narrative interviews identified common roles and characters within the stories that were told. Combining these findings with existing theoretical frames, particularly identity dissonance theory, a model was created that demonstrates a cycle of identity crisis that 'unprofessional' students seem to experience. Engagement with stakeholders further highlighted the problematic assumptions that limit the possibilities for remediation of professionalism lapses. The findings of this programme of research led to the creation of a proactive, strategic framework for remediation, founded in principles of equity and inclusion. This framework includes changes necessary in the environment of medical institutions to make space for diverse interpretations of professionalism; intensive faculty development, including the training of 'professional remediators'; and individual remediation through longitudinal coaching relationships. In conclusion, there is a clear mandate for approaching remediation more equitably in order to ensure the medical workforce of the future is equipped to care safely and professionally for patients.