Design, participants and setting: Qualitative study including five focus groups between 2 June 2010 and 30 September 2010, comprised of medical students from both undergraduate and postgraduate entry programs who were in the last 1–2 years of the medical program and had undertaken rural longitudinal integrated clinical placements.
Results: The five focus groups ran for a total of 5.5 hours. Participants (16 women and 24 men; mean age, 26 years [range 23–32 years]) expressed a low regard for the ways in which professionalism had been taught and assessed in their learning programs. They “gamed the system”, giving assessors the results on reflective writing assignments that they believed would gain them a pass. They considered experiential learning — observing good professional practice — to be the best way (some view it as the only way) to learn professionalism and consolidate what they learned, and formed their individual mental model of professionalism through group reflection with their peers in medical school.
Conclusions: While students will always be critical of their curriculum, the universal negative views we captured indicate that current teaching would benefit from review. We suggest a less didactic approach in early years, with more evaluation and feedback from students to assure relevance; an emphasis on true reflection, as opposed to guided reflections linked to overformalised requirements; and more attention devoted to role-modelling and mentoring in the clinical years of training.
Professionalism is an important component of medical training,1 yet there is scant research that captures the perspective on professionalism held by medical students2 or on the development of professional identity among doctors-in-training in general.3,4 Research is especially lacking on teaching methods and how the process of medical education moulds professional identity through the interactions that take place in practice settings5 and between generations.6
Professionalism training has, until recently, been more a product of the informal and hidden curricula — not so much taught, but assimilated through observation of the comportment and behaviour of tutors, clinical supervisors, residents and registrars.
More recently, the conceptual basis for teaching professionalism has been formalised.1
The literature contains few reports by medical students on their experiences with or reactions to the teaching of professionalism.7,8 Those that have been published are largely critical of the teaching of professionalism. The chief problem was the disjunction between what the curriculum taught and the observed conduct of their teachers,9-11 as well as the double standard between what is expected of students and what is freely tolerated in accepted members of the profession.11
The aim of our study was to discover what Australian medical students in the last 1–2 years of their program think about the way professionalism is taught in their medical curriculum. We sought to capture views students had developed as a result of their training and their views on how relevant they thought the training was.
Participants included both undergraduate-entry and postgraduate-entry medical students in their final 2 years of study before internship in three medical schools in New South Wales. All students undertaking year-long rural clinical placements at the University Centre for Rural Health were invited to participate through student coordinators (administrative personnel in charge of managing the logistics of student placements) to avoid intimidation and ensure that students who did not wish to participate felt secure in declining the offer. A summary of participant characteristics can be found in Appendix 1.
We held five focus groups between 2 June 2010 and 30 September 2010. The groups were developed by both authors (medical educators for over 20 years) and conducted by one (H B). Scripts for focus groups were designed to elicit students’ conceptual understanding of professionalism as well as their views on professionalism training (see Appendix 2).
Focus groups were audio-recorded and the recording transcribed verbatim for thematic analysis. The coding system was developed through reading the transcribed text and deriving coding categories. Thematic analysis was carried out using NVivo version 8 (QSR International).
The five focus groups ran for a total of 5.5 hours. Of the 40 student participants, 16 were women and 24 were men. The mean age was 26 years (range, 23–32 years). Fourteen participants (8 women, 6 men) were of ethnic origins other than white Australian. Most participants (30) were from homes in regional areas, as opposed to capital cities (10). Most students were enrolled in courses that identified the curriculum dedicated to the attributes of professionalism in medicine as “personal and professional development”, or PPD.
Twelve major themes related to concepts of professionalism, teaching methods and assessment methods were derived from the data (Box).
I know some people, or at least one I can think of, who’ve failed part of the course on PPD, and they probably clearly needed to because they were so outside the bounds of what would be expected to be acceptable behaviour.
Like 90% of the situations you encounter every day it’s an outcome of your upbringing and your life experience, and someone standing up and saying, “You shouldn’t do this, you shouldn’t do that,” is not going to be what you remember when you see the patient with the problem.
Stupid university reflections.
95% of us get it, and the folks here that don’t get it are not going to change their minds by this lecture.
It’s not legitimate, you know? Dr [name omitted] is really, really legitimate because [the person is a doctor].
But couldn’t you make the argument that PPD has more to do with psychology than with anything else, so that would be . . .
You just can’t relate to it when it’s psychological. They can’t really relate to what you actually do when you’re a doctor, and that’s what you need, somebody who can really tap in and understand what you need.
Students felt that a seminar-style instructional setting worked better than a lecture format. Reflecting back on their early training, they felt they received the most value from presentation of a dilemma involving ethical or legal issues, with a challenge to decide a proper course of action guided by an ethicist or medicolegal expert. They considered education on the theme of professionalism to have more relevance and more value later in their training. Participants thought that professionalism should be taught in a practice context, not as a stand-alone module removed from clinical elements of their training.
It seems more relevant now than it does in the first years.
I think . . . [general practice] has been the biggest learning curve of PPD for me . . . in that you also model what you see as well. You really start to become a lot more like the doctors that you spend the majority of time with, I think.
. . . and I think you have continued exposure to the same patients and you start forming relationships with those patients, and I think that tests a lot of your personal and professional boundaries, and you’re living in the community that you’re working in, that’s also building and learning about your boundaries. It’s just different to seeing a patient in the hospital, they’re there for two days, you go and say, “Can I please examine you?” You examine them, you never see them again. You don’t form that kind of relationship.
Communal learning, especially reflective debriefings with peers, was considered by these students to be important, if not essential, whereas individual learning experiences were hardly mentioned. Students relied on each other for reflection on their learning and for moral support, and felt that this solidarity within a student cohort contributed more to their professional development than any other single aspect of their training or clinical experiences. They reported that their sense of professionalism was improved by their informal discussion of the teaching they were exposed to and the experiences they were having on placement.
My mentors are the students around me, and I think that’s not assessed at all. Like, we talk to each other about everything all the time, and that’s not being noticed by the university as a form of PPD, and yet I think for me it’s the most important form of PPD.
In our [problem-based learning] groups, if there’s an ethical component to the case it gets discussed just naturally, not with any prompting or forwarding or anything like that, just around our kitchen table. We regularly discuss.
All three medical schools used written reflection as an aid to learning professionalism and for assessment. Students found these reflections artificial, restrictive and frustrating, and the scenarios too simplistic:
We see amazingly ethical conundrums all the time, and we discuss them just because we care about our patients and we care about what happens to people . . . The natural ones you find are always more interesting than the ones that they give you.
I wrote a true one, my first one was true, and I failed it, and since then I’ve written fictional ones . . . and I’ve got excellents.
It didn’t fit the criteria, the formula. So yeah, I failed it. Since then I’ve got all excellents for every one, and every one’s been engineered completely by following the criteria.
Students saw a need for different professional attributes in different sub-specialties, viewing specialties like anaesthesiology and pathology as needing few of the attributes that are of crucial importance for a general practitioner. On one occasion, students speculated on the filtering effect this may have on candidates for intensive specialties with less direct patient contact than general practice:
Maybe that’s why we have a shortage of pathologists and radiologists, because we’re excluding those people from our courses due to their total incompetence with patients, but no people person wants to do that job.
The responses to the professionalism component of the curriculum described by the medical students from three medical schools in NSW who attended our focus groups resonate with those of other students reported in the literature.8,9,11,12 There is common ground with regard to viewing assessment methods as being too narrowly focused13 and designed in a way that does not elicit students’ own views and experiences but, instead, elicits what examiners want to hear,9 as well as viewing course content as repetitive and patronising.14 They resent receiving cursory reviews of portfolios and reflective pieces that they have agonised over15 and writing reflective pieces to get a grade rather than to truly reflect on their experience.16
Students’ views were very consistent — there were no dissenting voices. This may reflect unanimity due to a convergence of thought among this group of peers who had been living and studying together under an intense curriculum over several years. In this case, the focus group could have served as a welcome outlet to crystalise and vent frustrations. It is also possible that dissenting participants may have felt intimidated, as can occur in focus groups. As these students appeared confident and opinionated, individually and collectively, we consider the latter to be unlikely.
As has been demonstrated elsewhere,15,17 students reported a disjunction between their ideals and those the set reflection pieces were designed to elicit, leading to their jaded view of such assessments and their willingness to submit whatever they felt necessary to pass. However, reflective exercises have been found to have substantial value18,19 in enabling a student to define their own mental model of what it means to be professional.
These students do not see themselves as being dishonest in providing reflections that match what their assessors want to see. It is well known that medical students offer resistance to curricular exercises they see as trivial or time-wasting,11,14 which is how these students viewed their professionalism curriculum. Their own view of their integrity and honesty remains intact, it is just expedient, in the context, to deliver what is needed in order to advance to the next stage in their training. The danger is that they are learning to go through the motions of being professional without that professionalism being grounded in a fundamental belief in the virtues that should underpin it. One study found that students were jaded by professionalism being “shoved down [their] throats”.14
The students in our focus groups had little regard for professionalism being taught by someone other than a doctor who had practice experience. Other authors have cautioned that attempts to teach professionalism using non-medical teachers will not be seen as credible by students.20
Extensive discussion within their peer group about ethical problems, communication issues and other aspects of professionalism appears to be an important activity in the development of professionalism in medical students,19 albeit one that is part of the hidden, rather than the formal, curriculum. The students we spoke with seemed to be engaging in critical reflection, rather than merely revisiting superficial details of an experience. There is value when the reflective process, as an extension of what is required for assessment, catalyses the kind of joint reflection these students engaged in, testing with each other what they learned and what they experienced.
Studies such as this one are useful for identifying the disjunction between what is intended to be taught and what is actually learned. Directions for improving the teaching of professionalism in medicine could include incorporating greater feedback from students and longitudinal follow-up of students to ascertain their professional development over time. A potential weakness inherent in focus groups is that the dialogue that emerges tends to be the dominant one within a group, with shyer participants not contributing, and dissenting thoughts left unsaid. Since these students had long experience and familiarity with each other as a group, we consider it unlikely that such intimidating factors were present among these individuals, who appeared to have a high level of trust within the group. It may also be that as they have spent considerable time reflecting on their medical education program, and the professionalism aspect of it, the views expressed during the focus group were already a distillation of commentary and reflection that these groups had collectively engaged in.
While students will always be critical of their curricula, the unanimously negative view we captured from the group of students interviewed indicates that current teaching would benefit from review. We suggest a less didactic approach in early years, with more evaluation and feedback from students to assure relevance, emphasis on true reflection (as opposed to guided reflections linked to over-formalised requirements) and more attention devoted to role-modelling and mentoring in the clinical years of training.
Twelve emergent themes describing medical students at three medical schools in New South Wales, 2010
had a low regard for the professionalism teaching they had experienced
held a pragmatic conceptual framework (definition) of professionalism based on their experience and reflection
did not report that they had experienced bullying or flagrant unprofessional behaviour in their training
did not accept the legitimacy of someone other than a doctor with clinical practice experience teaching them professionalism
consolidated what they learned, and formed their individual mental model of professionalism, through group reflection with their peers in medical school
had learned to “game the system”, giving assessors the results on reflective writing assignments that they believed their assessors wanted to hear, and that would gain them a pass
had a low regard for the ways in which professionalism had been assessed in their learning programs
saw a difference in the capacity and necessity for professionalism (especially regarding empathy and communication skills) between various medical specialties (eg, general practitioners need more than anaesthetists and pathologists)
valued the teaching of ethics and the legal parameters in which they must operate
saw the situations they experienced in clinical placements as being far more complex than the ones they were presented with in didactic teaching sessions, which they considered superficial or trivial
considered experiential learning — observing good professional practice — to be the best way (some view as the only way) to learn professionalism
seemed confident in their developing professional identities, including a healthy life–work balance
Received 17 December 2012, accepted 7 May 2013
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