Editorials
Ethics
Volume 199 - Issue 6

Can professionalism be taught?

Authors:  Ian M Symonds and Nicholas J Talley

Med J Aust 2013; 199 (6): 380-381. || doi: 10.5694/mja13.10656
Published online: 16 September 2013
Medical students’ values evolve over time, so a learning process involving meaningful feedback and immersion in a workplace culture that consistently promotes professional behaviour is desirable.
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Yes, but a more strategic approach should replace didactic methods

Public confidence in professional standards in medicine has not only been undermined by high-profile scandals such as those in Alder Hey, Bristol and Bundaberg, but also by the failure of the profession to identify and discipline its errant members. Doctors who are subject to disciplinary action are three times as likely as their peers (95% CI, 1.9–4.8) to have been identified as having behavioural problems as medical students.1 Medical program developers have increasingly tried to include teaching on “professionalism” in undergraduate curricula,2 and yet, as Birden and Usherwood report in this issue of the Journal, students have a low regard for the way in which this is done.3

Professionalism forms the basis of the relationship between doctors, their patients and the community they serve; but exactly what professionalism is continues to be subject to debate. Epstein and Hunderts’ definition of professional competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served”4 reminds us that clinical competence is a key aspect. However, professionalism is mostly discussed in terms of what might be called ethical conduct. The Physicians’ Charter describes three key domains of professionalism in medicine: the primacy of patient welfare (altruism, trust, patient interest); patient autonomy (honesty, patient empowerment, education); and social justice (using available resources and equity).5 Expectations around professionalism are at least now well documented. The Accreditation Council for Graduate Medical Education in the United States has identified professionalism as a core competency for doctors.6 Similar emphasis is placed on professional conduct by medical councils in the United Kingdom and Australia.

There is evidence that current strategies for teaching professionalism have limited effectiveness. Teaching can be in the form of dedicated sessions on aspects of professional behaviour. Quality improvement, patient safety and interprofessional learning are often a focus of such sessions. Birden and Usherwood have shown that students feel formal didactic teaching sessions on professionalism are of little value,3 so it is not surprising that this approach does not appear to have any lasting effect on student behaviour, much less the beliefs that underpin it.4,7 Students are far more significantly influenced by reflective debriefing with their own peers3 and by the processes, pressures, and constraints that make up the “hidden curriculum”.8 Students can learn about professional behaviour from poor examples of it but need appropriate opportunities to reflect on their experiences and discuss these with a mentor or their peers. Seeing examples of good practice is far more powerful.3

So, in terms of professionalism, what can we do to better equip not only students, but those in practice — and how? Role modelling has traditionally been the principal means by which students learn professional values and remains an important method.3 Good role models inspire others by exhibiting clinical competence, teaching skills and positive personal qualities.9 But as important as this informal learning is, we argue that a more strategic approach is now required. The key components should include student selection, setting expectations, performing assessments, remediating inappropriate behaviour and implementing cultural change.10

In selecting students for medical school, a variety of strategies to assess attributes other than academic ability have been tried, but there is little evidence for any one instrument being predictive of later professional conduct. More recently, there has been greater emphasis on excluding applicants with values and character traits that are at odds with the attributes of a doctor, rather than simply ranking candidates, but it is unclear whether a selection strategy based on such an approach would reduce the incidence of later professional misconduct.11,12

Assessment of professional conduct remains difficult but is essential for driving behavioural change. In a survey of medical programs in the US in 1998, 90% offered formal teaching in professionalism but only 55% had any form of formal summative assessment of this aspect.13 Students are especially critical of the way in which professionalism is assessed and how this encourages gaming of the system.3 No single instrument is able to measure all aspects of professionalism — a range of instruments and multiple observations over time are needed for both formative and summative assessment.14 This has led to increasing interest in using workplace-based assessment strategies to assess professional behaviour.14 Peer appraisal is a potentially powerful workplace-based assessment instrument,15 although it may be ineffective unless it is seen as valued by the organisation.16

Remediation relies on having suitable mechanisms for formative assessment, development of skills in reflection, and sufficient time for behaviours to change. Decisions on progression based on summative assessment of behaviour without opportunities for remediation are likely to be seen as punitive, value based and part of a hidden curriculum.

Perhaps most challenging, and yet most crucial, is bringing about changes in workplace culture. Culture will likely defeat any curriculum; zero tolerance for unprofessional behaviour must become the norm and peers must not turn a blind eye. The issue of faculty development here is crucial. Educational institutes also have a responsibility to show leadership in ensuring that students are supervised by appropriately trained staff.2

While there is general acceptance that professionalism needs to be a key part of the future of medical training,2 accomplishing meaningful outcomes from this is as complex as the subject itself. Student behaviour reflects the values they bring with them into medical school, and these evolve over time by a process of exploration and reflection.7 As Birden and Usherwood point out, overt curriculum content on professionalism, no matter how well designed or intentioned, is unlikely to be effective in changing behaviour unless aligned with the hidden curriculum of workplace culture and meaningful feedback.3

Authors

  • Ian M Symonds MD, FRCOG, FRANZCOG1,2
  • Nicholas J Talley MD, PhD, FRACP1
  • 1. Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW.
  • 2. Joint Medical Program, University of Newcastle and University of New England, NSW.

Correspondence: Nicholas.Talley@newcastle.edu.au

Competing interests

No relevant disclosures.

References

Provenance: Commissioned; externally peer reviewed.

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