Professionalism Required

A federal appeals court ruled Wednesday that Case Western Reserve University may revoke a medical degree it was forced by a lower court to award.

The reversal of the lower court is based on differing ideas on the deference that courts should give to colleges and universities on decisions about awarding degrees. The lower court ruled that because the issues at play were about the medical student's professionalism, not his academic performance, Case had to award the degree (which it then did). But a three-judge panel of the U.S. Court of Appeals for the Sixth Circuit ruled that the professionalism issues raised by Case were central to its concept of medical education, and thus deserved judicial deference.

The case involves a medical student (and until Wednesday's ruling an M.D.) named Amir A. Al-Dabagh. Court documents indicate that he did well academically, but had a series of problems related to what Case officials viewed as unprofessional conduct. He was consistently late to discussion sections and at least once admitted that he asked a faculty member not to record him as late even though he was.

He was accused of groping and propositioning female students at a medical school dance (he denied doing so). He was accused of jumping out of a moving taxi to avoid paying (he admitted to jumping out but said he did so because someone was assaulting him). Many nurses and hospital staffers complained about his demeanor in patient visits, and a patient's family once kicked him out of the room. (He said that his negative reviews in the hospital were related to his criticism of a superior.)

Finally, Case moved to deny him a medical degree (very shortly before he was scheduled to receive it) in April 2014 after he was convicted in North Carolina of driving while intoxicated. (Al-Dabagh said he wasn't drunk and crashed into a utility pole to avoid hitting a deer.)

A federal judge ordered Case to award the medical degree, finding that the various issues around Al-Dabah's professionalism were not academic matters on which universities should receive deference.

"While Case should receive great discretion in judging academic standards, the determination of 'professionalism' goes well beyond academic or patient-related matters. The university's definition of 'professionalism' expresses a moral judgment, rather than an evaluation against a set of specialized criteria," wrote Judge James S. Gwin. "Case describes professionalism in moral judgment terms: 'ethical, honest, responsible and reliable behavior'; 'respectful dialogue'; 'personal limitations and biases, and 'professional and interpersonal behavior.'"

He added that while courts should "give almost complete deference to university judgments regarding academic issues, the same deference does not follow university character judgments, especially on character judgments only distantly related to medical education."

The appeals court, however, said that the lower court had created a false distinction between professionalism and academic performance. In medical education, the appeals court ruled, professionalism is part of what students must learn and practice.

"Anyone who has ever been to a doctor’s office knows the value of a good bedside manner. That is why Case Western does more than just teach its students facts about the human body. Its curriculum identifies nine 'core competencies.' First on the list is professionalism. Medical knowledge does not make an appearance until the fifth slot," the ruling said.

The decision notes that professionalism requirements are stated in various places in the student handbook, and that these rules should not surprise any student.

"The [student conduct] committee’s professionalism determination is an academic judgment. That conclusion all but resolves this case," the appeals court said. "We may overturn the committee only if it substantial[ly] depart[ed] from accepted academic norms when it refused to approve Al-Dabagh for graduation. And given Al-Dabagh’s track record -- one member of the committee does not recall encountering another student with Al-Dabagh’s 'repeated professionalism issues' in his quarter century of experience -- we cannot see how it did."

Further, the appeals court rejected Al-Dabagh's argument that professionalism can only be judged by in-class behavior. "Even if professionalism is an academic criterion, Al-Dabagh persists that the university defined it too broadly," the appeals court decision said. "As he sees it, the only professional lapses that matter are the ones linked to academic performance. That is not how we see it or for that matter how the medical school sees it. That many professionalism-related cases involve classroom incidents does not establish that only classroom incidents are relevant to the professionalism inquiry, and Al-Dabagh has identified no case holding that the concept must be defined so narrowly."