“They liked it if you said you cried”: how medical students perceive the teaching of professionalism

Hudson H Birden and Tim Usherwood
Med J Aust 2013; 199 (6): 406-409. || doi: 10.5694/mja12.11827
Published online: 16 September 2013


Objective: To discover what Australian medical students think about the way professionalism is taught in their medical curriculum.

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.


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).

Teaching professionalism

Students had a low opinion of the way professionalism is currently taught at their universities.



Redundancy and oversimplification in the teaching of professionalism were recurring themes:

Students challenged the legitimacy of lecturers who were not medically qualified:



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.

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.

Assessing professionalism

Students also held a dim view of the PPD assessment methods of their medical schools. One student described them as “arbitrary and useless and trivial”.

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:

Students quickly learned to “game the system”, writing their reflections to meet the assessment criteria and obtain the desired result (a pass).



Students saw value in patient assessment of medical students, in including professionalism in an objective structured clinical exam, and in personal reflection.


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

As has been found elsewhere,14,21,22 clinical learning situations had more impact than classroom-based learning.

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


Received 17 December 2012, accepted 7 May 2013

  • Hudson H Birden1,2
  • Tim Usherwood3

  • 1 University Centre for Rural Health, North Coast, Lismore, NSW.
  • 2 Centre for Values, Ethics, and the Law in Medicine, Sydney School of Public Health, University of Sydney, Sydney, NSW.
  • 3 Westmead Clinical School, University of Sydney, Sydney, NSW.



We thank the students who participated in this research for their time and thoughtfulness, and the University of Sydney Postgraduate Award Program and the Australian Rural Health Research Collaboration for financial support.

Competing interests:

Tim Usherwood is a clinical teacher at one of the universities whose students participated in this study.

  • 1. Gordon J. Fostering students’ personal and professional development in medicine: a new framework for PPD. Med Educ 2003; 37: 341-349.
  • 2. Finn G, Garner J, Sawdon M. ‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study. Med Educ 2010; 44: 814-825.
  • 3. Reis DC. Who am I and why am I here? Professionalism research through the eyes of a medical student. Acad Med 2008; 83 (10 Suppl): S111-S112.
  • 4. Cohen MJ, Kay A, Youakim JM, Balaicuis JM. Identity transformation in medical students. Am J Psychoanal 2009; 69: 43-52.
  • 5. Apker J, Eggly S. Communicating professional identity in medical socialization: considering the ideological discourse of morning report. Qual Health Res 2004; 14: 411-429.
  • 6. Borges NJ, Manuel RS, Elam CL, Jones BJ. Comparing millennial and generation X medical students at one medical school. Acad Med 2006; 81: 571-576.
  • 7. Skiles J. Teaching professionalism: a medical student’s opinion. Clin Teach 2005; 2: 66-71. doi: 10.1111/j.1743-498X.2005.00063.x.
  • 8. Fehser J. Teaching professionalism: a student’s perspective. Mt Sinai J Med 2002; 69: 412-414.
  • 9. Brainard AH, Brislen HC. Viewpoint: learning professionalism: a view from the trenches. Acad Med 2007; 82: 1010-1014.
  • 10. Reddy ST, Farnan JM, Yoon JD, et al. Third-year medical students’ participation in and perceptions of unprofessional behaviors. Acad Med 2007; 82 (10 Suppl): S35-S39.
  • 11. Leo T, Eagen K. Professionalism education: the medical student response. Perspect Biol Med 2008; 51: 508-516.
  • 12. Monrouxe LV, Rees CE, Hu W. Differences in medical students’ explicit discourses of professionalism: acting, representing, becoming. Med Educ 2011; 45: 585-602.
  • 13. Byszewski A, Hendelman W, McGuinty C, Moineau G. Wanted: role models–medical students’ perceptions of professionalism. BMC Med Educ 2012; 12: 115.
  • 14. Wear D, Zarconi J. Can compassion be taught? Let’s ask our students. J Gen Intern Med 2008; 23: 948-953.
  • 15. Levenson R, Atkinson S, Shepherd S. The 21st century doctor: understanding the doctors of tomorrow. London: The King’s Fund, 2010. (accessed May 2013).
  • 16. Hays R, Gay S. Reflection or ‘pre-reflection’: what are we actually measuring in reflective practice? Med Educ 2011; 45: 116-118.
  • 17. Thompson BM, Teal CR, Rogers JC, et al. Ideals, activities, dissonance, and processing: a conceptual model to guide educators’ efforts to stimulate student reflection. Acad Med 2010; 85: 902-908.
  • 18. Mann K, Gordon J, MacLeod A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract 2009; 14: 595-621.
  • 19. Howe A, Barrett A, Leinster S. How medical students demonstrate their professionalism when reflecting on experience. Med Educ 2009; 43: 942-951.
  • 20. Gordon JJ, Evans HM. Learning medicine from the humanities. In: Swanwick T, editor. Understanding medical education: evidence, theory and practice. Oxford: Wiley-Blackwell, 2010: Ch. 6.
  • 21. Roberts LW, Green Hammond KA, Geppert CM, Warner TD. The positive role of professionalism and ethics training in medical education: a comparison of medical student and resident perspectives. Acad Psychiatry 2004; 28: 170-182.
  • 22. Michalec B. Clinical experiences during preclinical training: the function of modeled behavior and the evidence of professionalism principles. Int J Med Educ 2012; 3: 37-45. doi: 10.5116/ijme.4f42. 5c99.


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