Teaching professional development in medical schools

Critical incidents as a technique for teaching professionalism

BACKGROUND

The issue of professional behavior in medicine has been extensively discussed in the medical literature and clarity regarding what constitutes professional behavior, and strategies for assessing professionalism have begun to emerge.

AIM

To address the information gap on effective strategies for teaching professionalism.

METHODS

The critical incident technique (CIT) established by Flanagan has proven to be a useful way to structure teaching and/or evaluation of professionalism.

RESULTS

By analyzing 'real-life' occurrences of unprofessional behavior with learners, the CIT yields common terminology and definitions of professionalism that can be explored within a structured framework for discussion.

CONCLUSIONS

CIT is a versatile strategy as it can be utilized with varied audiences (e.g., students, faculty), in a wide array of settings (e.g., workshops, grand rounds). Examples of CIT use associated with teaching professionalism are reviewed and key features associated with its success are identified.

Promoting professional behaviour in undergraduate medical, dental and veterinary curricula in the Netherlands: evaluation of a joint effort

BACKGROUND

From 2002 onwards, a nationwide working group of representatives from all medical (8), dental (3) and veterinary medicine (1) schools collaborated in order to develop and implement recommendations for teaching and assessing professional behaviour.

AIM

The aim of this article is to describe the outcomes of this process, including hurdles encountered and challenges to be met.

METHOD

By a qualitative survey, information was requested on teaching professional behaviour, assessment, instruments used, consequences of unprofessional behaviour and faculty training.

RESULTS

All schools have adopted at least parts of the 2002 recommendations. Differences exist mainly in the organisational structure of teaching and assessment as well as in the assessment instruments used. In all schools a longitudinal assessment of professional behaviour was accomplished.

CONCLUSION

All schools involved have made progress since 2002 with regard to teaching and assessment of professional behaviour, resulting in a shift from an instrumental to a cultural change for some schools. A stimulating factor was society's call to focus on patient safety and therefore on assessment of unprofessional behaviour. Hurdles yet to be taken are the involvement of students in the assessment process, teacher confidence in personal assessment capacities, remediation programmes and logistic and administrative support.

Teaching and learning professional behavior in practice

This paper is the fourth article in a series on Professionalism and provides an overview of current methods used for teaching and learning about professionalism. The questions "whether" and "how" professionalism can be placed in the formal medical school curricula are addressed, and the informal learning related to professionalism reviewed.

Training and learning professionalism in the medical school curriculum: current considerations

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned. This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.

Medical and nursing students' television viewing habits: potential implications for bioethics

Television medical dramas frequently depict the practice of medicine and bioethical issues in a strikingly realistic but sometimes inaccurate fashion. Because these shows depict medicine so vividly and are so relevant to the career interests of medical and nursing students, they may affect these students' beliefs, attitudes, and perceptions regarding the practice of medicine and bioethical issues. We conducted a web-based survey of medical and nursing students to determine the medical drama viewing habits and impressions of bioethical issues depicted in them. More than 80% of medical and nursing students watch television medical dramas. Students with more clinical experience tended to have impressions that were more negative than those of students without clinical experience. Furthermore, viewing of television medical dramas is a social event and many students discuss the bioethical issues they observe with friends and family. Television medical dramas may stimulate students to think about and discuss bioethical issues.

Making interprofessional education work: the strategic roles of the academy

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Learning to be a doctor while learning anatomy!

This article presents results from a longitudinal study following a cohort of medical students. Semistructured interviews are conducted every year, in which the students tell about their experiences learning medicine, their daily life, and their social activities in relation to university. The aim of the study is to analyze how medical students develop their professional competencies, values, and attitudes. This article focuses on the medical student's professional development in relation to the process of studying and learning anatomy. We analyze interviews conducted while the students are in their third and fifth semester. Anatomy plays a significant role in the medical student's educational process, on both a cognitive and emotional level. It seems that students in learning the subject matter adapt to fundamental values in the medical profession and are thus transformed into real medical students, sharing a unique experience. The implications for curricular development and professionalism are discussed, and this article argues that the issue of professionalism must be addressed in the educational process in the preclinical years and in relation to the basic sciences.

Integrating professionalism teaching into undergraduate medical education in the UK setting

This paper examines how professionalism teaching might be integrated into undergraduate medical education in the United Kingdom setting. It advocates adopting an outcome-based approach to curriculum planning, using the Scottish Deans' Medical Curriculum Group's (SDMCG) outcomes as a starting point. In discussing the curricular content, potential learning methods and strategies, theoretical considerations are explored. Student selection, assessment and strategies for optimising the educational environment are also considered.

Ethics education

This article briefly describes the background and status of medical education in the areas of ethics and professionalism. Methods of teaching and assessment are described for medical students, residents, and practitioners within the core competency framework of medical education. Key areas of content for child and adolescent psychiatrists are described.

The influence of personal and environmental factors on professionalism in medical education

BACKGROUND

Professionalism is a critical quality for physicians to possess. Physician professionalism has received increased attention in recent years, with many authorities suggesting that professionalism is in decline. An understanding of the factors contributing to professionalism may allow the development of more effective approaches to promoting this quality in medical education.

DISCUSSION

We propose a model of personal and environmental factors that contribute to physician professionalism. Personal factors include distress/well-being, individual characteristics, and interpersonal qualities. Environmental factors include institutional culture, formal and informal curricula, and practice characteristics. Promotion of professionalism requires efforts directed at each of these elements.

SUMMARY

One responsibility of medical education is to foster the development of professionalism among its learners. Both personal and environmental factors play a role in physician professionalism. Accordingly, institutions should consider these factors as efforts to promote physician professionalism evolve.

Electronic discussion forums in medical ethics education: the impact of didactic guidelines and netiquette

OBJECTIVES

The quality of computer-mediated asynchronous group discussion in educational settings often has potential for improvement. To this end, 2 categories of recommendations can be found in the literature. Some authors advise providing didactic guidelines to students. Others recommend informing students about the basics of (formal) network etiquette (netiquette). This paper investigates whether the type of guideline provided has an effect on either or both the quality of asynchronous group discussion and the appraisal of participants in the context of a course in medical ethics.

METHODS

A total of 112 students graduating in the biomedical sciences were randomly assigned to electronic discussion groups of 18-19 participants each. Three treatment groups were created by varying the guidelines presented to participants upon entering the discussion forum. Guidelines contained trivial information, netiquette advice, or a combination of didactic guidelines and netiquette advice.

RESULTS

Both the quality of discussion and the participants' appraisal of the discussion were highest in the third group. However, contrary to what is widely suggested, it was observed that exclusively supplying netiquette guidelines had no impact on discussion quality.

CONCLUSIONS

To improve the quality of asynchronous group discussion, it is advisable to provide not only netiquette rules, but also didactic guidelines. Future research should focus on the effects of netiquette guidelines on students of different levels and skills and should allow for disentangling the effects of netiquette and didactic guidelines. It might also seek to establish methods of disseminating guidelines that enhance their effect.

Teaching professionalism in the early years of a medical curriculum: a qualitative study

CONTEXT

Despite the growing literature on professionalism in undergraduate medical curricula, few studies have examined its delivery.

OBJECTIVES

This study investigated tutors' and students' perspectives of the delivery of professionalism in the early years of Glasgow's learner-centred, problem-based learning (PBL), integrated medical curriculum.

METHODS

A qualitative approach was adopted involving semistructured interviews, on a 1 in 6 sample of tutors involved in teaching in the early curricular years, and 3 student focus groups. The findings were subjected to between-method triangulation.

RESULTS

Involvement in teaching raised students' and tutors' awareness of their professionalism. Learning activities promoting critical reflection were most effective. The integration of professionalism across the domains of Vocational Studies (VS) was important for learning; however, it was not well integrated with the PBL core. Integration was promoted by having the same tutor present throughout all VS sessions. Early patient contact experiences were found to be particularly important. The hidden curriculum provided both opportunities for, and threats to, learning. The small-group format provided a suitable environment for the examination of pre-existing perspectives. The portfolio was an effective learning tool, although its assessment should be formalised.

CONCLUSIONS

Reflection is integral to professional development. Early clinical contact is an important part of the process of socialisation, as it allows students to enter the community of practice that is the medical profession. Role models can contribute powerfully to students' learning and identity formation. As students move towards fuller participation, the clinical milieu should be controlled to maximise the influence of role models, and opportunities for guided reflection should be sustained.

Junior medical students' notions of a 'good doctor' and related expectations: a mixed methods study

OBJECTIVE

To explore junior medical students' notions of a 'good doctor', given their ideas about: success in Year 1, house jobs, and their attraction to medicine.

METHODS

Study participants were junior medical students (1999 and 2001 entry cohorts studied thrice and twice, respectively) and prospective students of the University of Liverpool's 5-year, problem-based, community-orientated curriculum. Data collection and analysis used a 'mixed methods' approach, cross-sectional design, and brief questionnaire surveys. In an index survey, open questions (analysed inductively) explored house jobs and Year 1 success. They also generated 'good doctor' themes, which a second survey confirmed and 3 surveys ranked. A sixth survey explored motivation for choosing medicine (open question). Good doctor rankings were analysed by postcode for prospective medical students classified as school-leaver residents of England and Wales.

RESULTS

Response rates were: 91.4% (973) of the 2001-02 admission candidates, on interview days; 68.0% (155), 61.2% (137) and 77.9% (159) of the 1999 cohort (at entry, end-Year 1 and mid-Year 3, respectively), and 71.0% (201) and 71.0% (198) of the 2001 cohort (at entry and end-Year 1, respectively). From 9 themes generally compatible with self-reported motivations and expectations, junior and prospective medical students consistently valued a good doctor as a 'compassionate, patient-centred carer' and a 'listening, informative communicator' over an 'exemplary, responsible professional'. Prospective students from less affluent English and Welsh postcodes valued 'efficient, organised self-manager' very slightly more highly (r(s) = - 0.140, P = 0.003).

CONCLUSIONS

This research provided empirical evidence to support ongoing commentary about patients mostly seeking qualities related to communication, caring, and competence in doctors. Weak evidence that socio-economic status might affect notions of a good doctor is worth pursuing.

A randomized comparison trial of case-based learning versus human patient simulation in medical student education

OBJECTIVES

Human patient simulation (HPS), utilizing computerized, physiologically responding mannequins, has become the latest innovation in medical education. However, no substantive outcome data exist validating the advantage of HPS. The objective of this study was to evaluate the efficacy of simulation training as compared with case-based learning (CBL) among fourth-year medical students as measured by observable behavioral actions.

METHODS

A chest pain curriculum was presented during a one-month mandatory emergency medicine clerkship in 2005. Each month, students were randomized to participate in either the CBL-based or the HPS-based module. All students participated in the same end-of-clerkship chest pain objective structured clinical examination that measured 43 behaviors. Three subscales were computed: history taking, acute coronary syndrome evaluation and management, and cardiac arrest management. Mean total and subscale scores were compared across groups using a multivariate analysis of variance, with significance assessed from Hotelling's T2 statistic.

RESULTS

Students were randomly assigned to CBL (n = 52) or HPS (n = 50) groups. The groups were well balanced after random assignment, with no differences in mean age (26.7 years; range, 22-44 years), gender (male, 52.0%), or emergency medicine preference for specialty training (28.4%). Self-ratings of learning styles were similar overall: 54.9% were visual learners, 7.8% auditory learners, and 37.3% kinetic learners. Results of the multivariate analysis of variance indicated no significant effect (Hotelling's T2 [3,98] = 0.053; p = 0.164) of education modality (CBL or HPS) on any subscale or total score difference in performance.

CONCLUSIONS

HPS training offers no advantage to CBL as measured by medical student performance on a chest pain objective structured clinical examination.

The teaching of professional attitudes within UK medical schools: Reported difficulties and good practice

INTRODUCTION

The demonstration of appropriate attitudinal behaviour is crucial in the professional development of doctors. This study explores the experiences of UK medical schools in developing and assessing the behaviour associated with the attitudes of undergraduate medical students.

METHODS

A qualitative in-depth interview study was based on a questionnaire survey of all UK medical schools. Six heads of medical schools or their nominated representatives were interviewed. Outcome measures were the perceptions and experiences of developing and assessing appropriate attitudes and behaviour in their undergraduate students.

RESULTS

Aspects of the hidden curriculum, especially the negative role modelling encountered during clinical practice, were seen to undermine the attitudinal messages of the formal curriculum. Some participants believed that students could still qualify as doctors despite having inappropriate attitudes or behaviour. Others felt certain that this was now unlikely in their school, and this confidence seemed to be backed up with the knowledge that strategies, systems and structures were in place to detect and act upon poor behaviour.

DISCUSSION

The conviction that it is right to assess students on their attitudinal behaviour does not yet appear to be held consistently across all schools and we suggest that this may reflect some fundamental tensions arising from differing views about the essential elements of good medical practice, tensions that are also shaping the hidden curriculum.

Viewpoint: teaching respect for patients

Respect is a core value of medical professionalism. Respect for patients often manifests itself as an attitude, of which the physician is only partially self-aware. To teach respect means bringing it fully into consciousness. Physicians then should strive to make respect an inner quality, beyond being a behavior. The author illustrates the depth of feeling involved in respecting another person by citing passages from Let Us Now Praise Famous Men, James Agee's classic book that describes Depression-era tenant farmers. However, major barriers inhibit teaching of respect in clinical settings. The author proposes that synergies can be achieved that overcome the barriers by combining the effective modeling of respect in bedside teaching with formal teaching exercises involving patients and deep critical reflection using narratives wherein learners describe their experiences in patient care.

Medical students' perceptions in relation to ethnicity and gender: a qualitative study

BACKGROUND

The British medical student population has undergone rapid diversification over the last decades. This study focuses on medical students' views about their experiences in relation to ethnicity and gender during their undergraduate training within the context of the hidden curriculum in one British medical school as part of a wider qualitative research project into undergraduate medical education.

METHOD

We interviewed 36 undergraduate medical students in one British Medical School, across all five years of training using a semi-structured interview schedule. We selected them by random and quota sampling, stratified by sex and ethnicity and used the whole medical school population as a sampling frame. Data analyses involved the identification of common themes, reported by means of illustrative quotations and simple counts.

RESULTS

The students provided information about variations patterned by gender in their motivation and influences when deciding to study medicine. Issues in relation to ethnicity were: gaining independence from parents, perceived limitations to career prospects, incompatibility of some religious beliefs with some medical practices and acquired open-mindedness towards students and patients from different ethnic backgrounds. Despite claiming no experiences of gender difference during medical training, female and male students expressed gender stereotypes, e.g. that women bring particularly caring and sympathetic attitudes to medicine, or that surgery requires the physical strength and competitiveness stereotypically associated with men that are likely to support the continuation of gender differentiation in medical careers.

CONCLUSION

The key themes identified in this paper in relation to ethnicity and to gender have important implications for medical educators and for those concerned with professional development. The results suggest a need to open up aspects of these relatively covert elements of student culture to scrutiny and debate and to take an explicitly wider view of the influence of what has sometimes been called the hidden curriculum upon the training of medical professionals and the practice of medicine.

Developing and evaluating professionalism

Professional behaviour, being one of the domains of professionalism, is an area of medical education that has long been of concern to medical educators. At Hacettepe University, our main goal is to have students become conscious of professional identity, values, responsibilities and the physician-patient relationship. We welcome our new students with an opening ceremony on their first day and two months later, the students start the course called "Health-Illness Concepts and Medical Professional Identity". Students are expected to discuss the subjects given to them as scenarios or arguments. The aim of our study is to determine whether the course leads to a positive change in students' attitudes, indicating the attainment of those attributes that reflect professionalism. On the first and the last days of the course, a questionnaire was delivered to the students. Any positive change in preferences between the two questionnaires is identified as an achievement of that attribute. As a result we found that in all of the seven attributes there were positive changes in the students' attitudes. Positive changes varied from 48% to 84% and all were statistically significant. Using more interactive techniques helped the students to make larger percentage changes in their awareness of these professional attributes.

Discovering professionalism through guided reflection

Doctors need to identify and understand the professional behaviours of both themselves and others. In order for students to think critically about these issues we encouraged them to use the tenets of the General Medical Council's Duties of a Doctor as a framework in which to reflect on the actions of healthcare professionals at work. Although the critical incident technique is a well-known process for encouraging reflection, little is known about its usefulness for assessment purposes in this setting. We aimed to discover the validity, feasibility and educational impact of the critical incident as an assessment method for first year students undertaking guided reflection in the context of their first exposure to multi-professional health and social care experiences. First year medical students submitted two critical incidents they had observed during multi-professional health and social care attachments and an evaluation of their experiences. Students engaged in the reflective cycle on the professional behaviours of others providing evidence of a varied range of situations. With adequate preparation, junior students are able to reflect on social and healthcare experiences using the Duties of a Doctor as a framework. Critical incidents are a valid and feasible method for assessing students' reflections on professionalism, with good educational impact.

The role of gross anatomy in promoting professionalism: A neglected opportunity!

Professionalism is one of the six areas of competency defined by the Accreditation Council for Graduate Medical Education (ACGME). Unprofessional behavior is the single most common cause for disciplinary action against medical students in their clinical rotations, residents, and clinical practitioners. The Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) will like to see professionalism taught and evaluated across medical school. Gross Anatomy, with cadaver laboratory dissection, is in a unique position to preside over a rich number of activities where behaviors of professionalism can be taught, practiced, and rewarded. Such activities will be comparable to the behaviors of professionalism taught in clinical rotations. This article highlights the essential involvement and tools that can be used to teach, evaluate, and promote behaviors of professionalism accessible in the laboratory with cadaver dissection.

Patient confidentiality: Implications for teaching in undergraduate medical education

Respect for patient confidentiality is one of the core concepts of professionalism and should have high priority in medical education. Confidentiality should be introduced early in the curriculum so that students understand their ethical, professional, and legal obligations throughout their medical studies and later professional career. Anatomists have important opportunities for teaching professional values including confidentiality and should be major contributors to a multidisciplinary teaching on professionalism. Students should make a formal commitment to and be assessed on patient confidentiality in the context of professionalism. A Faculty development program on confidentiality and data protection will inform and support teachers in delivering these objectives. It is recommended that medical schools have a policy on patient confidentiality and a disciplinary procedure for the management of students who breach patient confidentiality.

Student-selected components in the undergraduate medical curriculum: a multi-institutional consensus on assessable key tasks

This paper describes further progress by the Northern Universities SSC Consortium in achieving consensus on the contribution of the Student Selected Components (SSCs) to undergraduate medical courses. Following the identification of common purposes and outcomes, the group has matched these to assessable key tasks which students may undertake in order to demonstrate competence on a range of attributes not normally fully assessed in the core curriculum. In some schools, SSCs may be the predominant route through which students gain exposure to research methods and reflective practice. In addition to opportunities to acquire knowledge and skills outside the core curriculum, SSCs can contribute towards enhancement of core skills. SSCs may also contribute to the overall longitudinal assessment of personal and professional development. The potential role of portfolios in maximizing student learning from SSCs is discussed, and future areas for development identified.

Assessing medical students' personalities: a parallel comparison of normed and perception-based metrics

Various methodologies have been applied in the study of physicians' and medical students' personalities. Little, however, has been reported on distinguishing medical students' self-perceptions from their objectively measured personality traits. 687 first-year medical students at three U.S. medical schools were administered the 16PF and a parallel, author-generated, self-rating form. Paired sample t tests yielded significant differences between students' perceived personality traits vs normed measures of these traits on 14 of 16 personality factor dimensions. Students self-attributed greater magnitudes of socially acceptable traits than their objective scores indicated, as well as less domineering, suspicious, and self-doubting. Implications for admissions and career counseling are discussed.

Viewpoint: today's professionalism: engaging the mind but not the heart

Professionalism is au courant in medicine today, but the movement to teach and evaluate professionalism presents a conundrum to medical educators. Its intent is laudable: to produce humanistic and virtuous physicians who will be better able to cope with and overcome the dehumanizing features of the health care system in the United States. However, its impact on medical education is likely to be small and misleading because current professionalism curricula focus on lists of rules and behaviors. While such curricula usually refer to virtues and personal qualities, these are peripheral because their impacts cannot be specifically assessed. The author argues that today's culture of medicine is hostile to altruism, compassion, integrity, fidelity, self-effacement, and other traditional qualities. Hospital culture and the narratives that support it often embody a set of professional qualities that are diametrically opposed to virtues that are explicitly taught as constituting the "good" doctor. Young physicians experience internal conflict as they try to reconcile the explicit and covert curricula, and they often develop nonreflective professionalism. Additional courses on professionalism are unlikely to alter this process. Instead, the author proposes a more comprehensive approach to changing the culture of medical education to favor an approach he calls narrative-based professionalism and to address the tension between self-interest and altruism. This approach involves four specific catalysts: professionalism role-modeling, self-awareness, narrative competence, and community service.

A qualitative study of the perceptions and experiences of Pre-Registration House Officers on teamwork and support

BACKGROUND

Following the implementation of a new final Year 5 curriculum in one medical school we carried out a study to explore the experience of the transition from final student year to Pre-Registration House Officer (PRHO). This study looks at the experiences of two successive cohorts of PRHOs in relation to team work, support and shared responsibility in their transition from final year students to qualified doctors. The involvement of PRHOs in teams is likely to change in the development of Foundation programmes.

METHODS

A qualitative study with semi-structured interviews with 33 PRHOs, stratified by gender, ethnicity and maturity, from two study cohorts, qualifying in 2001 and 2002, from one medical school in the UK, in their first three months following medical graduation.

RESULTS

Most PRHOs reported positive experiences for their inclusion as a full member of their first ward teams. This contributed to their increasing confidence and competence in this early period of career transition. However, a number of organisational barriers were identified, e.g. incomplete teams, shift work, which produced problems in their integration for one third of newly qualified doctors.

CONCLUSION

Recently introduced policies, intended to improve the working lives of newly qualified doctors have produced both benefits and unintended adverse impacts on PRHOs. The changes of the new PRHO Foundation programme will have further impact. Foundation doctors may need to relate to wider teams with more interaction and less protection. Such changes will need to be managed carefully to protect the PRHO at a vulnerable time.

Perceptions of dissection by students in one medical school: beyond learning about anatomy. A qualitative study

INTRODUCTION

The practice of dissection, as part of undergraduate medical education, has recently resurfaced in the public eye. This paper focuses on a number of important learning outcomes that were reported by Year 1-5 medical students in a British medical school, during the dissection sessions in the first 2 years of their training, as part of a wider qualitative research project into undergraduate medical education.

METHODS

A group of 29 students was selected by quota sampling, using the whole student population of the medical school as the sampling frame. Qualitative data were collected by 1 : 1 interviews with students and from formal non-participatory observations of dissection sessions.

RESULTS

Apart from learning to cope with the overt 'emotional confrontation' with the cadavers which assists anatomical learning, 7 additional covert learning outcomes were identified by the students: teamwork, respect for the body, familiarisation of the body, application of practical skills, integration of theory and practice, preparation for clinical work, and appreciation of the status of dissection within the history of medicine.

DISCUSSION

A number of medical schools have either removed the practical, hands-on aspect of dissection in the medical undergraduate curriculum or are seriously considering such a measure, on financial and/or human resource grounds. This study highlights the fact that dissection can impart anatomical knowledge as well as offer other relevant, positive learning opportunities to enhance the skills and attitudes of future doctors.

Sources of ethical conflict in medical housestaff training: a qualitative study

PURPOSE

Despite increased emphasis on medical ethics and professionalism in medical education, concern about unethical and unprofessional behavior by physicians is widespread. This study sought to identify and classify the range of work-related ethical conflicts experienced by medical house officers.

METHODS

We performed a qualitative study using data from in-depth interviews conducted in 2001 with 31 internal medicine residents in one traditional and one primary care residency. Using the constant comparative method, we explored work-related experiences during housestaff training that involved ethical conflict with patients or colleagues.

RESULTS

The interviews revealed five categories of ethical conflict: concern over telling the truth, respecting patients' wishes, preventing harm, managing the limits of one's competence, and addressing performance of others that is perceived to be inappropriate. Conflicts occurred between residents and attending physicians, patients or families, and other residents. Many of the conflicts were exacerbated by the function of the hierarchical structure in residency training.

CONCLUSIONS

This study provides a classification of work-related ethical conflicts that houseofficers experience, which may be used to improve the working environment for residents and support their professional development. By attending to the challenges that residents face, particularly previously underemphasized conflicts concerning competence and performance, this framework can be used to enhance education in ethics and professionalism.

A physician charter on medical professionalism: a challenge for medical education

The European Federation of Internal Medicine, The American College of Physicians-American Society of Internal Medicine, and the American Board of Internal Medicine recently developed a Charter on Medical Professionalism that they hope will be accepted by physicians around the world. The charter is based on three principles: the primacy of patient welfare, patient autonomy, and social justice. We believe that each of these principles has relevance to medical education and practical implications. Based on the obligations of the charter, we believe that medical educators should consider the attribute of altruism in making admission decisions, enhance moral development in medical schools, develop a curriculum in quality improvement, explore further the use of patient simulation, and renew their efforts to incorporate knowledge of the basic sciences into clinical training. Furthermore, we believe they should ensure that students protect patient confidentiality, ensure role-model appropriate interactions with pharmaceutical companies, teach students how gender, race, and socioeconomic status have an impact on health care, require electives in underserved areas, and incorporate the charter into courses on medical ethics. Medical educators must also ensure that the curriculum and learning climate at their institutions support the values articulated in the charter.

Assessing students' personal and professional development using portfolios and interviews

BACKGROUND AND PURPOSE

Medical schools are placing more emphasis on students' personal and professional development (PPD) and are seeking ways of assessing student progress towards meeting outcome goals in relation to professionalism. The Faculty of Medicine at the University of Sydney sought an assessment method that would demonstrate the value of reflection in attaining PPD, provide feedback and encourage students to take responsibility for setting and achieving high standards of performance.

METHODS

The instruments used to assess Year 1 students in PPD are a portfolio and interview. This assessment format encourages students to explore ideas and values that are important to them and relevant to the PPD theme. A confidential interview, based on the PPD goals, is held with a faculty member who has read the student's portfolio.

RESULTS

In 1997/98, 96% of students agreed that they had engaged in useful reflection on their approach to the course and 91% agreed that the experience was worthwhile. A further 76% of students agreed that they could see opportunities to modify their approach in some ways as result of this exercise.

CONCLUSION

Sustained PPD is essential in equipping doctors for the varied stresses of careers in medicine. Despite, or perhaps because of, the latitude in the Year 1 assessment, both students and faculty members found the process of value. This form of assessment acknowledges that the most valid assessment formats cannot always be made reliable and that in some parts of the curriculum it is more important to demonstrate trust in students' own motivation to become competent and mindful practitioners. The fact that the portfolio and interview are the only summative assessments in the first year emphasises the importance that the Faculty places on PPD.

Fostering students' personal and professional development in medicine: a new framework for PPD

CONTEXT

Altruism, accountability, duty, integrity, respect for others and lifelong learning are qualities that have been identified as central to medical professionalism. However, we do not have a systematically developed understanding of what is needed to optimise medical students' personal and professional development (PPD). We need some level of agreement on how to teach and assess PPD, but traditional educational methods may not be strong determinants of students' or graduates' actual behaviour in clinical settings.

AIMS

This paper considers the factors that demonstrably influence doctors' behaviour as a contribution to the development of a model for considering PPD within the broader context of medical practice. The model presented acknowledges that behaviour change comes about through a number of influences including education, feedback, rewards, penalties and participation. These elements can be plotted against the cognitive, affective and metacognitive processes that are intrinsic to learning.

IMPLICATIONS

A framework that promotes the consideration of all of these factors in PPD can provide guidance for schools undergoing curriculum reform and inform further research into one of the most important and challenging aspects of medical education.

Teaching professionalism to residents

The need to teach professionalism during residency has been affirmed by the Accreditation Council for Graduate Medical Education, which will require documentation of education and evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has proposed the following components of professionalism be taught and measured: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The authors describe a curriculum for introducing the above principles of professionalism into a pediatrics residency that could serve as a model for other programs. The curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions devoted to addressing key professionalism issues. The authors also explain how the retreat is evaluated and how the retreat's topics are revisited during the residency, and discuss general issues of teaching and evaluating professionalism.

Pharmacological education under the Medical Education Model Core Curriculum

The objectives of undergraduate medical education have been shifted drastically during the last decades. As the world standard, basic medical knowledge, skill, and attitude to practice patient-centered medical care became main objectives in undergraduate medical education. In response to these changes in the environment of medical practice and education, the Medical Education Model Core Curriculum (MEMCC), was published in 2001. MEMCC describes general and specific behavioral objectives in an integrated form to be used in the practice of medicine. The achievement of MEMCC will be evaluated by the Nationwide Common Achievement Test. The test examines knowledge, skill, and attitude that is required for clinical clerkship. Pharmacological teachers in medical schools should discuss, study, and evaluate MEMCC based on their experience in the use of the curriculum. MEMCC and the Nationwide Common Achievement Test will enhance intra- and inter-disciplinary, as well as inter-institutional informational exchange in the context and strategies in pharmacological education.

The transition out of medical school - a qualitative study of descriptions of borderline trainee interns

OBJECTIVE

To describe the characteristics of borderline performance in final year medical students (trainee interns), as judged by their supervisors.

DESIGN

Qualitative study based on in-depth interviews followed by validation descriptions of borderline trainee interns identified prospectively over 12 months.

SETTING

Christchurch School of Medicine, University of Otago, New Zealand.

PARTICIPANTS

Fourteen supervisors of trainee interns chosen because of their experience and/or close contact with trainee interns.

MAIN OUTCOME MEASURES

Analysis of supervisors' narratives to identify key themes.

RESULTS

Borderline trainee intern performance occurs within a transition period from clinical student to doctor and is characterised by difficulty taking on a professional role. This difficulty may be manifest by not getting involved with the health care team, poor time management and occasionally by interpersonal difficulties or not recognising limits. Taking on a professional role requires ability in the clinical task, including diagnostic ability, which is built on a foundation of basic knowledge and clinical skills. These can be influenced by personal factors such as rigidity, motivation and shyness. Personal illness can affect performance at any stage.

CONCLUSIONS

The difficulties faced by borderline trainee interns fit a model of transition from competence as a student to performance as an intern. A sensitive marker of such difficulties is poor time management or not getting involved with the patient care team. Such difficulties may reflect more specific problems such as professional socialization, setting priorities, hypothesis generation, assigning probabilities to identified problems, integrating competing issues, recognising limits and learning when to call for assistance.