Preparing Program Directors to Address Unprofessional Behavior


All medical educators will inevitably need to manage challenging trainees. Even one “difficult” resident or medical student can wreak havoc on an educational environment. Program directors must manage this maelstrom and as a result tend to experience especially high levels of distress in relation to difficult trainees. Frustrated and resentful, they often feel “de-skilled” or ill-prepared to manage these unwelcome challenges. In this chapter, the authors provide a framework for understanding and working with this group of trainees and the problems they engender. The practical strategies that flow from this framework allow program leaders to develop realistic expectations and informed management approaches in relation to the predictable problems that arise in relation to difficult trainees. The authors further provide definitions of personality traits and personality disorders as a means of offering an explanation of how certain residents might pose problems in various aspects of training, and how to distinguish between those likely to do well with effective intervention and those likely to do poorly. Case vignettes illustrate examples of how maladaptive personality traits, across a range of severity, might manifest in a resident’s behavior. Finally, the authors provide an outline for how to approach an intervention with a resident exhibiting problematic behavior, including recommendations for managing the difficult aspects of the experience for the program director, communicating effectively with the resident, collaborating with faculty, and supporting other trainees.


Problematic Behavior Program Director Personality Trait Personality Disorder Unprofessional Behavior 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Dupras DM, Edson RS, Halvorsen AJ, Hopkins Jr RH, McDonald FS. “Problem residents”: prevalence, problems and remediation in the era of core competencies. Am J Med. 2012;125(4):421–5. doi: 10.1016/j.amjmed.2011.12.008.PubMedCrossRefGoogle Scholar
  2. 2.
    Tabby DS, Majeed MH, Schwartzman RJ. Problem neurology residents: a national survey. Neurology. 2011;76(24):2119–23. doi: 10.1212/WNL.0b013e31821f4636.PubMedCrossRefGoogle Scholar
  3. 3.
    Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA. 2000;284(9):1099–104. PubMed PMID: 10974688.PubMedCrossRefGoogle Scholar
  4. 4.
    Ratan RB, Pica AG, Berkowitz RL. A model for instituting a comprehensive program of remediation for at-risk residents. Obstet Gynecol. 2008;112(5):1155–9. doi: 10.1097/AOG.0b013e31818a6d61.PubMedCrossRefGoogle Scholar
  5. 5.
    American Board of Internal Medicine. IN: Materials from Association of Program Directors in Internal Medicine (APDIM)’s Chief Residents’ Workshop on Problem Residents. New Orleans, LA; 19 April 1999.Google Scholar
  6. 6.
    American Medical Association, Council on Ethical and Judicial Affairs, Southern Illinois University at Carbondale, School of Medicine, Southern Illinois University at Carbondale, School of Law. AMA code of medical ethics: current opinions with annotations. 2006–2007 ed. Chicago, IL: AMA Press; 2006. Physicians with Disruptive Behavior 9.045.Google Scholar
  7. 7.
    Sullivan C, Murano T, Comes J, Smith JL, Katz ED. Emergency medicine directors’ perceptions on professionalism: a council of emergency medicine residency directors survey. Acad Emerg Med. 2011;18(2):S97–103. doi: 10.1111/j.1553-2712.2011.01186.x.PubMedCrossRefGoogle Scholar
  8. 8.
    Katz ED, Dahms R, Sadosty AT, Stahmer SA, Goyal D; CORD-EM Remediation Task Force. Guiding principles for resident remediation: recommendations of the CORD remediation task force. Acad Emerg Med. 2010;17(Suppl 2):S95–103. doi: 10.1111/j.1553-2712.2010.00881.x
  9. 9.
    Sanfey H, Darosa DA, Hickson GB, Williams B, Sudan R, Boehler ML, Klingensmith ME, Klamen D, Mellinger JD, Hebert JC, Richard KM, Roberts NK, Schwind CJ, Williams RG, Sachdeva AK, Dunnington GL. Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems. Arch Surg. 2012;147(7):642–7. doi: 10.1001/archsurg.2012.832.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.New York University School of MedicineNew YorkUSA

Personalised recommendations