Volume 193 - Issue 11
The difficult problem: assessing medical students’ professional attitudes and behaviour
Authors: Malcolm H Parker, Jane Turner, Paul McGurgan, Lynne M Emmerton, Lindy L McAllister and David Wilkinson
Med J Aust 2010; 193 (11): 662-664. || doi: 10.5694/j.1326-5377.2010.tb04097.x
Published online: 6 December 2010
Published online: 6 December 2010
This report summarises the presentations, discussion themes and outcomes of the National Forum: Assessment of Professional Behaviour of Medical Students held in Brisbane on 5 March 2010
The behaviour of doctors and medical students has received increasing attention in recent years, but its assessment has resisted straightforward integration into academic programs. Attempts to prevent the admission of the small number of students who are unsuitable for graduation and subsequent practice are yet to prove effective.1,2 National registration will require that virtually all Australian health professional students are registered with their respective national body;3-5 these students will therefore formally become members of their professions. The accountability thereby imposed on students and their schools will set new expectations for managing student behaviour in universities.
In response to these issues, the Discipline of Medical Education, School of Medicine, University of Queensland (UQ) organised the National Forum: Assessment of Professional Behaviour of Medical Students, held in Brisbane on 5 March 2010. Participants confronted the conceptually and practically difficult problem of validly and reliably assessing the attitudes and behaviour of medical students as a component of their overall fitness to practise.
Participants
The forum was attended by 86 participants, including representatives of 13 Australian medical schools (from all mainland states), both New Zealand medical schools, Queensland Health and some of its public hospitals, the Medical Board of Queensland, the Health Quality and Complaints Commission of Queensland, the Australian Medical Council (AMC), medical student bodies, and other health professions. There were six presentations and two facilitated discussion sessions.
Setting the scene
In opening the forum, Professor Michael Keniger, Senior Deputy Vice-Chancellor, UQ, commented that issues relating to attitudes and behaviour are not restricted to medicine, and that an authoritative basis for a common approach is required, including the early detection of students who may pose problems later in their practices.
The Commissioner of Queensland’s Health Quality and Complaints Commission,6 Professor Michael Ward, noted that although serious individual breaches of professionalism attract the most public attention, problems occur at two levels — the individual practitioner (often driven, arrogant and narcissistic) and the profession, which is immersed in a culture of silence. Failure at both levels has powered the “engines of external regulation”, including complaints commissions.
Professor Ward suggested strategies that could be used to address these problems, including the avoidance of individual student selection “disasters”, the early identification of problem students, early responses to warning signs of aberrant practitioners, and individual remediation of both students and practitioners. Implicit in this is the need for the profession to raise “group intelligence”, deal with dysfunctional colleagues, and learn how to handle difficult conversations rather than turning a blind eye to poor practice.
The AMC, the accrediting body for Australian and New Zealand schools, understands that measuring professionalism is less well developed than assessment in other areas, such as clinical skills and knowledge of biology and pathology, but it expects and encourages schools to monitor and assess student behaviour in a manner consistent with the principles of its recent publication for independent practitioners, Good medical practice: a code of conduct for doctors in Australia.7 The Chair of the AMC’s Medical School Accreditation Committee,8 Professor Michael Field, indicated that behaviour assessment is accepted as a routine element of medical education and that schools are required to develop robust processes overseeing student behaviour — incorporating clear standards and criteria, defined consequences of failure, and rules for progression. Schools should offer student support and counselling, and identify and deal with students whose lack of professionalism or impairment affects their ability and performance. AMC accreditation visits have revealed a wide range of approaches to assessing professional behaviour, and Professor Field noted that despite the expectation that schools establish professional behaviour committees, their processes have not always been accepted into the mainstream assessment practices of the schools.
International experience
The keynote address was given by Professor Maxine Papadakis, an academic physician and Associate Dean for Student Affairs at the School of Medicine, University of California, San Francisco (UCSF) and one of the United States’ pre-eminent researchers in the assessment of medical professionalism. She recounted the development at UCSF of the process for managing student behaviour. Dismissal can occur on the basis of sustained failure, indicated by “physicianship evaluation forms” issued by course directors or associate deans according to agreed patterns.9,10
Professionalism as a requirement for graduation is supported by large-scale studies showing that unprofessional student behaviour predicts disciplinary action as a registered physician,11,12 and that student professionalism ratings predict factors influencing patient care.13 Professor Papadakis urged a strong research effort to improve our expertise in remediation methods and underscored the deficiencies of professional culture by arguing for the reciprocal assessment of teaching staff by students.
Current practice in Australia
Associate Professor Paul McGurgan (University of Western Australia) presented the results of a national survey on fitness-to-practise policies in Australian medical schools, a project conducted by senior medical students under his supervision (see Fitness-to-practise policies in Australian medical schools — are they fit for purpose?).14 The survey used the United Kingdom’s General Medical Council (GMC) categories of unprofessional behaviour for medical students,15 with a guiding assumption that fitness-to-practise policies should be developed in a nationally consistent way.
Fifteen of the 19 Australian schools participated; 12 of these had fitness-to-practise policies, and six addressed all eight of the GMC’s best-practice criteria, but with variation in referral and remediation criteria. Seven schools excluded students during the 5-year study period, the most common reasons being persistent inappropriate attitude or behaviour (eight students) and criminal convictions (four students). The study revealed a lack of consistency across the schools, suggesting that a move towards a more collaborative approach is possible and should improve outcomes.
Learning from other disciplines
Associate Professor Lindy McAllister (UQ) described the development of the COMPASS system of assessing of student performance in the discipline of speech pathology.16 The instrument has high validity and reliability and is used formatively during mid-rotation evaluations and summatively during end-of-rotation evaluations. Students are assessed in clinical settings directly and on multiple occasions; the assessment includes four generic competencies — reasoning, communication, lifelong learning and professionalism, including behaviour — and seven occupation-specific competencies. An at-risk notification of grossly or persistent unprofessional behaviour may result in a student being withdrawn from a rotation and not permitted to return until agreed and monitored remedial work is completed.
Student perspectives
Two students from the University of Queensland Medical Society17 presented the society’s views on how student behaviour should be assessed. They described UQ’s personal and professional development interview process for students flagged as needing assistance — in any area, including attitudes and behaviour — as fair and equitable, yet daunting and stressful for some students, with some persistence of the (albeit incorrect) perception of a punitive, disciplinary and inquisitorial process.
The students urged that satisfactory professional conduct be made a requirement for graduation, but called for better documentation of the rules and processes. They supported peer assessment, subject to the provision of adequate training, and a limited extension of behaviour assessment to social situations, where students are readily perceived as representatives of the school and the medical profession. They also pointed to social networking websites as possible settings for unprofessional behaviour.
Future imperatives
Associate Professor Malcolm Parker (UQ) clarified the obligations of medical schools under the (at the time) imminent national registration scheme’s governing legislation.18 The statutory reporting requirements leave medical schools with the responsibility of directly managing student impairment that does not pose a direct risk of harm to the public and managing all student behaviour issues. He argued that assessment should be of actual, not simulated, behaviour, and that many instruments do not fulfil this requirement. He also questioned the possibility of remediating certain students, the appropriateness and effectiveness of purely academic sanctions (such as repeating rotations) for failure on professional behaviour grounds, and the continuing allegiance to strict confidentiality concerning students as they move into practice, which constrains any pre-emptive oversight by registration authorities.
Participant perspectives
During the discussion sessions, participants raised the following issues and themes:
The airline industry’s safety model includes training in how junior staff can convey critical information (in both senses of critical) to their seniors — a model that medical education must embrace more comprehensively.
Unacceptable behaviour should be described objectively, rather than “diagnosing” personality traits and disorders in problem students.
Although students with narcissistic personalities can conceal their behaviour from senior staff, students can often discern problems, highlighting the value of peer assessment.
Peer assessment is valuable, but students’ sense of collegiality may minimise reporting rates.
Administration staff are valuable sources of information, as they deal with behaviour that students would not always display to teachers. They provide formal reports on student behaviour in some schools.
The responsibilities and scope of schools and students need to be clearly defined, so that judgements can be made reasonably and acted on.
Some teachers are reluctant to critically assess students or junior medical staff for fear of terminating potential careers, but this may be changed by steady peer pressure over time.
Students at younger ages may still be developing their “moral compasses”, but this can be accommodated by defining appropriate expectations for different stages and distinguishing these from criteria (such as honesty) that apply across programs.
Simulated clinical scenarios may provide information on behavioural tendencies by seeking students’ responses in different contexts.
Students should be positively encouraged to act professionally, and staff should provide feedback on good professional behaviour where appropriate.
The main points raised by the speakers and participants are summarised in Box 1, and the actionable outcomes that were agreed on are listed in Box 2.
1 Assessing medical student professionalism: where are we now?
The community expects doctors and other health professionals to behave appropriately.
Failure at the levels of individual performance and the response of the profession have driven an increase in external regulation.
The profession’s culture of silence about poorly performing peers reaches into student assessment and should be changed.
A small number of students should not graduate and practise, on the grounds of their unsatisfactory behaviour. Admission processes do not effectively prevent these students from entering medical programs.
Large-scale studies demonstrate that unprofessional student behaviour predicts later disciplinary action; student professionalism ratings predict quality of patient care.
Under national registration, the Medical Board of Australia will not be responsible for assessing students’ professional attitudes and behaviour in medical schools; this will continue to be the responsibility of medical schools.
The Australian Medical Council requires medical schools to support students and manage those who are impaired or demonstrate poor professionalism using clear standards and criteria, defined consequences of failure, and rules for progression.
Descriptive behavioural criteria and accompanying standards are required for robust assessment; these can accommodate the moral maturation of students.
Students strongly support assessment of professional behaviour, adequate documentation, and peer assessment with adequate training.
The majority of Australian medical schools have fitness-to-practise policies and processes, but there is wide variation in referral and remediation criteria and processes.
Assessment should arguably focus on actual behaviour, rather than behaviour observed during simulated situations, including formative and summative patient–student interactions, although simulations of various kinds can provide good teaching and feedback opportunities.
Assessment should include feedback on positive as well as poor behaviour.
Assessment should be accompanied by remediation, and adequate remediation requires further research.
2 Actionable outcomes of the National Forum: Assessment of Professional Behaviour of Medical Students
1. A forum report should be published in a major medical journal.
2. Representatives of the participants should write to the Medical Deans Australia and New Zealand,19 proposing that a trans-Tasman working group on the assessment of professional attitudes and behaviour be facilitated and supported.
3. The working group should define acceptable behaviour at different stages of a medical career; descriptors should be positive and inspirational. (The working group should also be involved in implementing outcomes 4–7.)
4. A nationally uniform approach should be adopted to align with the spirit and implementation of national registration and Good medical practice: a code of conduct for doctors in Australia.7
5. Further exploration and research should be undertaken in the areas of teaching professionalism, assessment processes and remediation. This includes collation of curricula in the related areas of ethics, law and professionalism.
6. Further academic articles should be published, covering descriptive and empirical work in assessment and remediation.
7. Any revision of the previously published position statement An ethics core curriculum for Australasian medical schools20 should more adequately address professional behaviour, its assessment, and its relationships with teaching ethics and law.
Competing interests
None identified.
References
- Parker MH, Wilkinson D. Dealing with “rogue” medical students: we need a nationally consistent approach based on “case law”. Med J Aust 2008; 189: 626-628. 0_i1095511
- Wilkinson D, Zhang J, Byrne GJ, et al. Medical school selection criteria and the prediction of academic performance. Evidence leading to change in policy and practice at the University of Queensland. Med J Aust 2008; 188: 349-354. 0_i1095514
- Australia’s Health Workforce Online. National Registration and Accreditation Scheme. http://www.nhwt.gov.au/natreg.asp (accessed Mar 2010).
- Australian Health Practitioner Regulation Agency [website]. http://www.ahpra.gov.au (accessed Mar 2010).
- Medical Board of Australia [website]. http://www.medicalboard.gov.au (accessed Mar 2010).
- Health Quality and Complaints Commission [website]. http://www.hqcc. qld.gov.au (accessed Mar 2010).
- Australian Medical Council. Good medical practice: a code of conduct for doctors in Australia. http://www.ahpra.gov.au/Health-Professions/Medical/Codes-and-Guidelines.aspx (accessed Nov 2010).
- Australian Medical Council. Assessment and accreditation of medical schools: standards and procedures, 2009. http://www.amc.org.au/images/Medschool/standards.pdf (accessed Mar 2010).
- Papadakis MA, Osborn EHS, Cooke M, Healy K. A strategy for the detection and evaluation of unprofessional behavior in medical students. University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee. Acad Med 1999; 74: 980-990. 0_i1095527
- Papadakis M, Loeser H, Healy K. Early detection and evaluation of professionalism deficiencies in medical students: one school’s approach. Acad Med 2001; 76: 1100-1106. 0_i1095529
- Papadakis MA, Hodgson CS, Teherani A, Koatsu ND. Unprofessional behaviour in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004; 79: 244-249. 0_i1095531
- Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005; 353: 2673-2682. 0_i1095533
- Papadakis MA, Arnold GK, Blank LL, et al. Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. Ann Intern Med 2008; 148: 869-876. 0_i1095535
- McGurgan PM, Olsson-White D, Holgate M, Carmody D. Fitness-to-practise policies in Australian medical schools — are they fit for purpose? Med J Aust 2010; 193: 665-667. 0_i1095537
- General Medical Council (UK); Medical Schools Council (UK). Medical students: professional behaviour and fitness to practise. http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp (accessed Mar 2010).
- McAllister S, Lincoln M, Ferguson A, McAllister L. COMPASS: competency assessment in speech pathology. Melbourne: Speech Pathology Association of Australia, 2006. 0_i1095541
- University of Queensland Medical Society [website]. http://uqms.org (accessed Mar 2010).
- Health Practitioner Regulation National Law Act 2009 (Qld) ss 5, 86-93, 143-144. 0_i1095545
- Medical Deans Australia and New Zealand [website]. http://www.medicaldeans.org.au (accessed Mar 2010).
- Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools (ATEAM). An ethics core curriculum for Australasian medical schools. Med J Aust 2001; 175: 205-210. 0_i1095551