“Just culture” approach to lapses in professionalism

During my first few months of general practice in North Vancouver in the mid-1950s, one of the senior internal-medicine doctors asked me if I could make a daily short visit to one of his patients while he was away for couple of weeks. The patient was a young woman, slowly dying with mitral valve endocarditis. She was more or less isolated in an oxygen tent in the middle of a 10-bed ward waiting for her death. In those days there was not much more that could be done for her. The senior physician put his hand on my shoulder and said, “your visits will help her, use your bedside manner.” 

During that time hospital stays were long and general practitioners and specialists visited their patients frequently. I never had a course on bedside manner, but during my internship I often heard nurses quietly comment to each other about the good bedside manners of some of the attending doctors. These doctors were confident and honest, but with kindness. They were all busy, yet had time to listen and hold a hand, even when that hand was a dying patient’s. Today’s patient stays in hospitals tend to be short. Much of the care is very technical, with complex procedures and machinery involved, nurses, aids, various technicians, and therapists floating around busily with fewer visits by doctors—and possibly no visit at all from the usual family doctor, who may not be on the hospital’s staff.

In this context a doctor’s professionalism, not their bedside manner, is the new measuring stick of a good practitioner, and the measuring stick for upcoming residents in training. Professionalism is hard to define as it sometimes refers to a pattern of behavior, at other times to a set of skills or some unspecified medically related cultural virtue. As a consequence, assessing lapses in the professionalism of physicians or our trainees becomes challenging. For instance, in the context of residency training the “we know it when we see it” approach to pinpoint a trainee’s lapses may be inadequately addressed. 

A recent article in the New England Journal of Medicine recognizes this problem. The authors recommend abandoning the “blame culture” in favor of a “just culture” framework that combines identification of the kind of error or lapse with an educational approach. The proposal suggests that medical errors and lapses in professionalism should be separated. Medical errors would be identified as inadvertent errors, at-risk behaviors, or reckless behaviors, to be responded to with the relevant and appropriate consoling, coaching, or disciplining of the trespasser. 

Lapses in professionalism would be identified by their nature—not quite the fault of the trainee, a minor violation, or major unprofessional behavior. The article provides examples of some of these behaviors. In the “just culture” the approach to the lapse would be the relevant support and advice, remediation, or discipline.
In contrast to the “blame culture” the “just culture” is an educational approach to difficult problems. It looks at human mistakes as learning opportunities for the organization and its members. It distinguishes various kinds of lapses, and it provides for fairness and consistency in the response, avoiding biased reactions or mistreatment of the practitioner or the trainee. 
—George Szasz, CM, MD 

Suggested reading
Kullgren JT, Lowenstein J. Can you teach professionalism? . . . and if you can, how? Virtual Mentor 2003;5:435-437.

Wasserman JA, Redinger M, Gibb T. Responding to unprofessional behavior by trainees – A “just culture” framework. N Engl J Med 2020;382:773-777.

Wikipedia. Just culture. Accessed 8 April 2020. https://en.wikipedia.org/wiki/Just_culture.

This post has not been peer reviewed by the BCMJ Editorial Board.

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