Medical Professionalism

The Dimensions That All Medical Students Should Know About

by Amila Punyadasa

 

Introduction

It is prudent to commence this chapter with some relevant definitions. A profession is a specific type of occupation, one that performs work with special characteristics while competing for economic, social, and political rewards. A professional, it follows, is a person who belongs to a group (profession) which possesses specialized characteristics (specifically, knowledge, skills, and attitudes) that have been obtained after a long period of study and are used to benefit other members of society. Thus, professionalism is used to describe those skills, attitudes and behaviors. We expect from individuals during the practice of their profession and includes such concepts as maintenance of competence, ethical behavior, integrity, honesty, altruism, service to others, adherence to professional codes, justice, respect for others and self-regulation. In fact, it has been said that professionalism serves as the basis of the medical professions’ relationship to society and that this relationship is a social contract, underpinned by professionalism. Medical professionalism thus comprises physicians’ behaviors that demonstrate they are worthy of the trust the public and patients place in them.

In essence, our profession involves healing. Kirk (2007) eloquently stated that in any patient encounter, we consider both a right and good healing strategy for our patients. The right action is informed by evidence-based medicine, while the good action incorporates the patient’s values and preferences aligned with the physician’s judgment (or, in other words, requires the physician to exercise various dimensions of professionalism).

Interestingly, this ‘judgment’ itself has three concrete steps:

1. The diagnostic question – What is wrong with the patient? – Incorporates both the clinical assessment and investigations the patient was subjected to.
2. The therapeutic question – What can be done for the patient? – Informed by evidence and may involve a plethora of treatments and interventions.
3. The prudential question – What should be done for the patient? – This involves the patient in the final decision-making process, preserves patient autonomy, and ensures a patient-centric approach to healthcare provision.

The advantages of teaching students to practice professionalism include imparting a greater sense of purpose, building a framework for harmonious and efficacious healthcare provision, as well as building trust and mutual respect. Additional benefits include improving patient satisfaction, reducing complaints and litigation, improving treatment compliance, and improving clinical outcomes.

Although there are many definitions of professionalism, most contain a list of responsibilities that the physician should exercise; they are based on three fundamental principles:

1. The principle of primacy of patient welfare – This is based on a dedication to serving the interest of the patient with altruism; in turn, contributing to trust, the core of the doctor-patient relationship. This principle should be unsullied by economic, administrative or sociocultural exigencies.
2. The principle of patient autonomy – The patient’s autonomy must be respected, and doctors should not only be honest with their patients but also empower them to make informed decisions about their healthcare, as long as these are within the ethical practice and do not lead to demands for inappropriate care.
3. The principle of social justice – This includes the fair distribution and access to health care resources and the elimination of discrimination, whether that be racial, gender-based, religious, socio-economic or any other social category.

The definition proposed by Wilkinson et al. (2009) is both thorough and explicit. His list of specific behaviors necessary for medical professionalism is enumerated. Also incorporated in the appendix is the Emergency Medicine Clerkship’s core curriculum learning objectives that pertain to professionalism.

• Honesty/Integrity
• Confidentiality
• Moral reasoning and ethical decision making
• Respecting privileges and codes of conduct
• Effective Interactions with Patients and Their Relatives
  • Respect for diversity
  • Politeness/Courtesy/Patience
  • Manners/ Demeanor
  • Patient-centered and involved decision-making process
    Maintenance of professional boundaries
  • Balancing availability to others with care of ones-self
• Effective Interactions with Other Health Care Workers
  • Teamwork
  • Respect for diversity
  • Politeness/Courtesy/Patience
  • Maintenance of professional boundaries
  • Manner/Demeanor – This includes maintaining a professional appearance.
  • Balancing availability to others with care of ones-self
• Reliability
• Accountability/task completion
• Punctuality
• Assumes responsibility and is conscientious
• Self-Reflectiveness
• Recognizing limits
• Life-long learning
• Dealing with uncertainty
• Teaching and debriefing
• People management
• Leadership
• Using appropriate strategies to improve processes
• Advancing knowledge and one’s field (e.g. via Research)

Seven deadly sins of professionalism or professional non-virtues. They are the following:

1. Greed – with respect to money, power, and fame.
2. Abuse of power – with respect to colleagues, patients, and position in the hierarchy.
3. Arrogance – towards patients or colleagues
4. Conflict of Interest
5. Misrepresentation – for example, lying or being fraudulent.
6. Apathy – pertaining to lack of commitment, irresponsibility or doing the bare minimum for patients.
7. Impairment – secondary to illness, alcohol or drugs.

Many of the core criteria of professionalism are related to the assimilation of good old-fashioned virtues and the development of soft skills that must not only be taught but also reinforced through modeling and active practice. When devising any professional curriculum, take careful consideration of common themes that positively impact necessary behavioral changes. Some of those themes include the following:

1. Motivation (or Getting “Buy-In”)
   1. Intrinsic – Medical students must be convinced of the importance of the desired change in behaviors for it to be a driving force.
   2. Extrinsic – The principal extrinsic motivator for medical students is the knowledge that professionalism will not only be explicitly taught but also explicitly tested (or assessment driven learning and practice). Other motivators include bestowing rewards and recognition for demonstrating positive behaviors, a form of positive reinforcement.
2. Observing role models are of the utmost importance. This entails not only the incorporation of good behaviors observed but also the recognition of negative behaviors exhibited by poor role models and purposefully not engaging in such behaviors. I shall delve into this concept in more detail in part 4 below.
3. Continued exposure to aspects of professionalism is important to inculcate its tenets. Vertical integration into a spiral curriculum, in my opinion, is required to achieve this goal.
4. Reflection and feedback are keys. Self-reflection on aspects of professionalism, as well as timely and effective feedback of specific behaviors from peers and seniors, will help mold the medical student into doctors that demonstrate professional behaviors. Good feedback, based on observable behaviors, explains not only what should be done but also why it should be done, and both are essential for effective learning.

The importance of teaching medical professionalism to undergraduates is well documented in the literature and is integral to the medical profession. What is perhaps less clear is exactly how this teaching should be conducted. The solution lies in understanding how to utilize all aspects of the curriculum including the formal, informal, and hidden curriculum.

Strategies for Teaching the Formal Curriculum

The following involves a discussion of the teaching of the “formal curriculum,” which is defined as the stated, intended, and formally offered and endorsed curriculum.

Maudsley & Strivens (2004) have proposed that the ‘situated learning’ theory seems to describe the most effective model to imbibe the virtues of professionalism. It suggests that learning should be embedded in authentic activities which help to transform knowledge from the abstract and theoretical to the usable and useful. Brown et al. (1989) further noted that there should be a balance struck between the explicit teaching of a subject and activities where the implementation of such knowledge is utilized in an authentic context.

Furthermore, there have been two principle approaches described in the teaching of professionalism.

• Explicitly Teaching the Basics of Professionalism
• Experiential Learning

One should utilize both of these approaches. In fact, to paraphrase the situated learning theory, a balance must be struck between knowledge-based teaching and in-situ experiential learning.

In my personal undergraduate and postgraduate training years, there has been a scarcity of teaching about professionalism, especially in the formal curriculum. Professionalism is not a gimmick but a set of rules and behaviors that each of us must adhere to and practice; it forms the very foundation of good clinical practice. Over the last 15 years, the undergraduate curriculum has increasingly incorporated medical professionalism, explicitly, as part of their formal curriculum; they do so with the application of both vertical and horizontal integration. This is the way forward.

The judicious instructor has a plethora of instructional modalities to choose from. The different teaching/learning strategies and tools that may be utilized to achieve competence across the many dimensions of medical professionalism successfully.

• Problem-based reflective practice
• Role-modeling
• Portfolio based training
• Clinical contacts with tutor debriefs
• Simulation-based training
• Didactics and tutorials

The Informal and Hidden Curricula in Medical Professionalism

The Informal and hidden curricula are, as the terms themselves suggest, not only cloaked in mystery but are also crucial elements of medical professionalism. The informal curriculum is defined as an unscripted and ad hoc yet highly interpersonal form of teaching and learning that takes place between faculty members and students in non-classical teaching settings. Examples of these ‘settings’ could include tearooms during clinical breaks or even a certain coffee house. Over coffee, I recently taught my 4th-year elective student about medical professionalism themes, including respect for the patient and their autonomy, citing anecdotes from my experience.

The hidden curriculum, on the other hand, is a set of influences that function at the level of organizational structure and culture. These two components are interrelated; In fact, some authors refer to both the informal and hidden curricula as one entity. Hence, it is clear that in order to acquire the knowledge, skills, and attitudes of professionalism, students must use a wide range of learning strategies that extend far beyond the intended formal curriculum. These strategies include interactions with teachers, colleagues and various other people around them.

Research has shown a distressing downtrend in professionalism, which has been directly attributed to the influence of a hidden curriculum. For example, empathy among medical students was seen to decrease as they progress through medical school.

Such surprising findings are noted despite increased emphasis being placed on the teaching of the formal curriculum. Thus, it becomes clear that these discrepancies may be attributed to the influence of the ‘hidden’ curriculum. Interestingly, some students believe that certain components of their learning could only be achieved through the informal and hidden curriculum and that the science of medicine is associated mainly with the formal curriculum while the art of medicine is associated mainly with the informal and hidden curricula.

It is well known that medical students acquire soft skills such as communication techniques and medical etiquette, both important facets of professionalism, from observing mentors, peers, and other healthcare workers.
Other modalities of learning via the informal and hidden curriculum are

• Rituals
• Infrastructure
• Chance Observations

It is quite clear to me that the formal, informal and hidden curricula are all complimentary. However, there is, unfortunately, an ongoing conflict between the formal curriculum and the informal/hidden curriculum.

An obvious remedy is to engage the various stakeholders involved in training medical students in a constructive dialogue on how the hidden and informal curricula can be manipulated to influence student learning positively. This understanding will not only help avoid the visible conflict between formal curriculum and informal/hidden curricula but will also extract the advantages of the informal/hidden curriculum to produce better physicians.

It is undeniable that medical school faculty, both senior and junior doctors, and other healthcare workers are all role models who may influence medical students’ learning. The professionalism demonstrated by all these people is of great importance not only for their patients but also for the next generation of doctors. Hence, we have to keep paramount in our minds that our practice and interpretation of professionalism, and all its dimensions, is keenly being observed by our students and that we have a huge role to play in the development and molding of their moral and professional wellbeing.

Role Modelling in Medical Professionalism

This connects back to the most powerful tool to teach professionalism, role modeling. Role modeling involves a physician (or role model) who teaches a student by example; its importance is unquestionable and has been documented for many years.

Classically, a role model is someone who is admired for the way he acts and for his professionalism and whose behavior is considered as a standard of excellence to aspire to.

It is important to show students what right practice is, and that applies to both clinical and professional conduct. This is the essence of role modeling.

Paice et al. (2002) described the act of being a role model as serendipitous, a beneficial but chance outcome. I respectfully disagree. Senior tutors and physicians all act as role models and must be cognizant of everything we do in front of our students. Knowing that we will be observed and scrutinized should make us ultra self-conscious, and we should try hard to showcase and inculcate the virtues of sound clinical practice and professionalism at every opportunity.

The vast majority of the literature is in agreement that role modeling is not only important but also integral to medical education. Role models not only affect the attitudes, behaviors, and ethics of medical students but also imbibe professionalism in trainees. I am sure we can all recall a specific role-model that impressed upon us the virtues of professionalism while demonstrating punctuality, responsibility, honesty, ethical reasoning, accountability, collegiality and patient-centric management while embracing diversity with a sense of decorum. Such role models also influence career choices of students and function in the formal, informal and hidden curricula. However, drawbacks have also been described. Sinclair (1997) wrote that he noted medical students being drawn to and indeed emulate senior doctors who held positions of responsibility and status. He further noted a warning of their professional ideals and behaviors as they evolved.

Assessment Techniques in Medical Professionalism

Unfortunately, despite the unquestionable importance of professionalism to the everyday functioning of every medical doctor and student, my experiences (spanning two decades and three countries) with its assessment has been rather limited. In fact, during my postgraduate years of clinical practice, the assessment of professionalism has been rather rudimentary, with its evaluation often subordinate to the assessment of clinical competencies.

If we are to take the assessment of professionalism seriously, then we must improve our framework for assessment. Specifically, we need to implement a number of different methods to effectively measure all levels of Miller’s pyramid, while also covering the multidimensional breadth of professionalism.

I shall now consider some assessment tools that will enable the ability to assess the multidimensionality of medical professionalism. These are;

• Assessment of an Observed clinical encounter
• Collated views of co-workers
• Simulation
• Paper tests
• Patient opinions
• Ratings by a Superior
• Self-assessment
• Critical incident report / Records of incidents of unprofessionalism

Social Media and Professionalism

It seems like nearly everyone, certainly from the Generations Y and Z, is using Facebook or Twitter these days for one reason or another. Although not a fan myself, I do concede that when used with prudence, social media and the Internet is an invaluable resource for teaching and learning. It can support physicians’ personal expression, improve camaraderie and improve the dissemination of public health messages. Equally, it risks broadcasting unprofessional content online that reflects poorly on individuals, their affiliated institutions, and the medical profession alike.

For example, let us consider a hypothetical tweet from a female doctor to her colleague describing a recent patient: ‘Just saw an 18-year-old unmarried G5P0, with Chlamydia, herpes, and gonorrhea. Disgusting!’ This tweet would have contravened a few of Wilkinsons (2009) so-called ‘behaviors inherent to good medical professionalism.’ This doctor should have had “respect for her patients’ diversity” and shouldn’t have been so judgmental (in this case, about the patients alleged sexual promiscuity and lifestyle). She also should have upheld patient confidentiality (as although the patient’s name wasn’t tweeted, the descriptors used about her obstetric and sexual histories would surely have made her easily identifiable amongst her friends and family who might have come across this tweet). The doctor should have, in my opinion, had better regard for professional boundaries and exercised greater judgment and discretion.

Defining unprofessionalism online and policing it has been challenging. However, with the increase in awareness of such occurrences, regulatory bodies have published various documents in an attempt to regulate physician’s activities on social media sites. The General Medical Council (GMC) has attempted to do exactly this with its paper. It warns against the blurring of boundaries between ones public and private lives and advices that privacy on these sites cannot be guaranteed. Furthermore, it stresses that physicians must be careful with regards to patient confidentiality, elaborating that although one piece of information may not breach confidentiality by itself, together, a few may certainly do so. In summary, physicians must be cognizant of patient confidentiality and privacy and monitor their Internet presence to ensure that information posted is both accurate and appropriate. With regards to interaction with patients through social media, again, this interaction should fall within the boundaries of established professional norms. If a physician feels that such an interaction transgresses such norms, he/she should report the matter to the relevant authorities. Finally, it is imperative that physicians realize that inappropriate online interactions may have a negative impact on their reputations and that of their institutions, career advancements, and, perhaps most damning, may serve to undermine public trust in the medical profession as a whole.

References and Further Reading

• Brown J.S., Collins A. & Duguid P. (1989) Situated cognition and the culture of learning. Educational Researcher; 18, pp. 32–42.
• Ginsburg S., Regehr G. & Lingard L. (2003) To be and not to be: the paradox of the emerging professional stance, Medical Education; 37(4): 350-7.
• Hochberg M.S., Kalet A., Zabar S., Kachur E., Gillespie C. and Berman R.S. (2010) Can professionalism be taught? Encouraging evidence. Am J Surg.; 199(1): 86-93
• Kirk L.M. (2007) Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent); 20(1): 13-16.
• Maudsley G. & Strivens J. (2004) Promoting professional knowledge, experiential learning & critical thinking for medical student. Medical Education; 34: 535–544.
• Paice E., Heard S. & Moss F. (2002) How important are role models in making good doctors? BMJ; 325:707-710.
• Richardson B.K. (2004) Feedback, Academic Emergency Medicine; 11(12): e1-e5.
• Sinclair S. (1997) Making doctors: An institutional apprenticeship. Oxford: Berg Publishers.
• Wilkinson T.J., Wade W.B. and Knock L.D. (2009) A Blueprint to assess Professionalism: Results of a systematic review. Acad Med.; 84(5):551-8.