• Pieter C Barnhoorn, Vera Nierkens, Marianne C Mak-van der Vossen, Mattijs E Numans, van MookWalther N K AWNKADepartment of Intensive Care Medicine and Academy for Postgraduate Medical Training, Maastricht University Medical Centre, Maastricht, the Netherlands.School of Health Professions Education, Maastricht University, Maastricht, the , and KramerAnneke W MAWMDepartment of Public Health and Primary Care, Leiden University Medical Center, Leiden, Hippocratespad 21, Zone V0-P, PO Box 9600, 2300 RC, Leiden, The Netherlands..
• Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Hippocratespad 21, Zone V0-P, PO Box 9600, 2300 RC, Leiden, The Netherlands. p.c.barnhoorn@lumc.nl.
• Bmc Fam Pract. 2021 Dec 20; 22 (1): 249249.

BackgroundLapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later practice requires timely identification and remediation. However, appropriate language to describe unprofessional behaviour and its remediation during residency is lacking. Therefore, this exploratory study aims to investigate which behaviours of GP residents are considered unprofessional according to supervisors and faculty, and how remediation is applied.MethodsWe conducted eight semi-structured focus group interviews with 55 broadly selected supervisors from four Dutch GP training institutes. In addition, we conducted individual semi-structured interviews with eight designated professionalism faculty members. Interview recordings were transcribed verbatim. Data were coded in two consecutive steps: preliminary inductive coding was followed by secondary deductive coding using the descriptors from the recently developed 'Four I's' model for describing unprofessional behaviours as sensitising concepts.ResultsDespite the differences in participants' professional positions, we identified a shared conceptualisation in pinpointing and assessing unprofessional behaviour. Both groups described multiple unprofessional behaviours, which could be successfully mapped to the descriptors and categories of the Four I's model. Behaviours in the categories 'Involvement' and 'Interaction' were assessed as mild and received informal, pedagogical feedback. Behaviours in the categories 'Introspection' and 'Integrity', were seen as very alarming and received strict remediation. We identified two new groups of behaviours; 'Nervous exhaustion complaints' and 'Nine-to-five mentality', needing to be added to the Four I's model. The diagnostic phase of unprofessional behaviour usually started with the supervisor getting a 'sense of alarm', which was described as either a 'gut feeling', 'a loss of enthusiasm for teaching' or 'fuss surrounding the resident'. This sense of alarm triggered the remediation phase. However, the diagnostic and remediation phases did not appear consecutive or distinct, but rather intertwined.ConclusionsThe processes of identification and remediation of unprofessional behaviour in residents appeared to be intertwined. Identification of behaviours related to lack of introspection or integrity were perceived as the most important to remediate. The results of this research provide supervisors and faculty with an appropriate language to describe unprofessional behaviours among residents, which can facilitate timely identification and remediation.© 2021. The Author(s).

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