Integrating professionalism teaching into undergraduate medical education in the UK setting

Understanding medical professionalism using express team-based learning; a qualitative case-based study

Medical Professionalism (MP) defined as values, behaviours and attitudes that promote professional relationships, public trust and patient safety is a vital competency in health profession education. MP has a distinctive uniqueness due to cultural, contextual, conceptual, and generational variations. There is no standard instructional strategy to probe the understanding of MP in a cohesive, structured, interactive manner. This study aimed to investigate undergraduate medical students' understanding of MP using express team-based learning (e-TBL) at both campuses of Royal College of Surgeons Ireland (RCSI). Using the key principles of a sociocultural theoretical lens in adult learning theory, we designed e-TBL as a context-learning-based educational strategy. We conducted three e-TBL sessions on cross-cultural communication and health disparities, a reflective report on clinical encounters, and professionalism in practice. We collected, collated, and analyzed the student experiences qualitatively using data gathered from team-based case discussions during e-TBL sessions. A dedicated working group developed very short-answer questions for the individual readiness assurance test (IRAT) and MP-based case scenarios for team discussions. In this adapted 4-step e-TBL session, pre-class material was administered, IRAT was undertaken, and team-based discussions were facilitated, followed by facilitator feedback. A qualitative inductive thematic analysis was performed, which generated subthemes and themes illustrated in excerpts. Our thematic analysis of data from 172 students (101 from Bahrain and 71 from Dublin) yielded four unique themes: incoming professional attitudes, transformative experiences, sociological understanding of professionalism, and new professional identity formation. This qualitative study provides a deeper understanding of medical students' perceptions of medical professionalism. The generated themes resonated with divergent and evolving elements of MP in an era of socioeconomic and cultural diversity, transformative experiences, and professional identity formation. The core elements of these themes can be integrated into the teaching of MP to prepare fit-to-practice future doctors.

Medical Professionalism and Ethics

Frequent media reports of disputes between medical teachers, resident doctors, and patients have been disturbing thus indicating an increasing gap and decline in the values of the profession. The foundation of medical professionalism and ethics is trust, truth, human values, and strong societal commitment. Our professional responsibilities as medical educators have immediate and long-term impact on the quality of training, patient care, and overall image of the professional group in the society. Formal teaching and training in professionalism and medical ethics that emphasize humanistic aspects and standard of conduct, respectively, are equally essential as biomedical aspects. Interestingly, the principles of medical ethics and attributes of professionalism overlap. However, real-life experiences and complex clinical scenarios place medical educators at the crossroads that contradict their professional commitments resulting in ethical dilemmas. COVID-19 pandemic has further challenged the principles of medical professionalism, especially patient welfare, autonomy, and social justice to prioritize patient care and make tricky decisions based on insufficient resources including withholding and withdrawing potentially lifesaving treatments. Unfortunately, until now the teaching and training in medical professionalism and ethics have remained subtle and medical students learn by chance. The recent introduction of the AETCOM module and Code of Medical Ethics in the curriculum is a ray of hope to brighten the image of medical professionals.

Fostering the Development of Professionalism in Veterinary Students: Challenges and Implications for Veterinary Professionalism Curricula

The importance of professional skills teaching and assessment within veterinary education has recently been highlighted in the veterinary education literature. This academic discourse follows the acknowledgement by both veterinary employers and graduates themselves that new graduates often lack the professional skills and attitudes needed for success in clinical veterinary practice. Traditionally, veterinary curricula have focused solely on teaching content knowledge and clinical skills; however, veterinary education curricula clearly must also contain dedicated instruction in veterinary professionalism. This must include instruction in communication skills, emotional intelligence, cultural awareness, teamwork abilities, dispute resolution strategies and the awareness that multiple approaches may be required to resolve challenges. It has become unrealistic to expect students to rely on observation and role modelling to foster the development of professionalism. There is a need to incorporate explicit learning activities that reinforce the knowledge, attitudes, values, and behaviours that characterise veterinary professionalism. While role modelling remains a key aspect of the veterinary professionalism learning that takes place through the informal/hidden curriculum, many students have often had more experiences with negative role models than with positive ones. This can lead to the development of a tolerance or normalisation of negative behaviours and a decline in students’ perceptions of professionalism. This article aims to continue recent conversations on professional skills teaching within veterinary education, define what is meant by veterinary professionalism and consider the plethora of terminology used when trying to establish a definition, highlight those attributes of veterinary professionalism deemed important by veterinary stakeholders for career success and employability, and explore the challenges of incorporating the teaching and assessment of professional traits into veterinary education.

A follow-up study on the effects of an educational intervention against pharmaceutical promotion

Background

The promotion strategies of pharmaceutical companies create many problems including irrational prescribing, diminished trust in the patient-physician relationship and unnecessary increases in pharmaceutical costs. Educating prescribers is known to be one of the few potentially effective measures to counteract those impacts. However such educational programs are limited in the literature, and their effectiveness against the effects of hidden curriculum in the long term is unknown. This study aims to evaluate the effectiveness of an education program both in the short term and the long term after the students have been exposed to informal and hidden curriculum and various pharmaceutical promotion methods.

Methods

A longitudinal and controlled study was carried out in a school of medicine in Turkey where there are no restrictive policies for pharmaceutical promotion. A survey was applied to 123 students who attended the class throughout the terms of 2011–12, 2012–13, and 2013–14, evaluating the pre-educational status of students’ opinions of promotion and any post-educational changes. A follow-up study four years later asked those three cohorts to fill out the same survey to see the possible effects of the clinical environment and various promotion methods. Also, the opinions of all 518 sixth-year students who had not taken the class in those three terms were compared to the educated students.

Results

The program was significantly effective in the short term in changing students’ opinions and attitudes positively towards recognizing companies’ discourse and promotion strategies. But in the long term, the education lost its ability to convince students of the importance of not getting financial support for scientific activities from pharmaceutical companies (p:0.006) and carrying out research (p<0.001). In addition, although the educated students were more aware that trivial gifts could influence prescriptions compared to the uneducated 6th year students (p<0.001), the difference between them and the uneducated students generally becomes less significant when they encounter the clinical environment. The study also evaluated students highly-exposed to promotion; for this sub-group, the educated students kept their consciousness level about the influences of trivial gifts (p<0.001) while the uneducated students were confident that they were immune to the influence of trivial gifts.

Conclusions

The education program could be used for creating awareness of, increasing skepticism towards, and inculcating disapproval about pharmaceutical promotion practices. However, the effectiveness of the educational intervention is susceptible to erosion after exposure to the informal and hidden curriculum together with exposure to promotion. The impact of role-models, organizational culture, and institutional policies could be important aspects to be addressed for sustaining the effectiveness of such education programs.

The impact of positive doctor role modeling

BACKGROUND

Role modeling has been highlighted as an important teaching and learning strategy. The aim of this research study was to explore the influences and impact of positive doctor role modelling in twenty-first century medical education.

METHODS

This study was part of a larger study investigating the process of positive doctor role modeling in medical education. This study used focus group interviews with 52 medical students, semi-structured interviews with 25 consultants and interviews after clinics with five consultants and five medical students. A qualitative methodology using the grounded theory approach of Strauss and Corbin was then used to explore the impact of modeling in medical education.

RESULTS

Three main outcomes of role modeling were identified - the development of professional behaviors, the development of professional identity, and the shaping of career aspirations.

CONCLUSION

This study illustrates the powerful, often subconscious impact of doctor role modeling in medical education. This research illustrates that role models are critically important in the professional development, character development, and career development of the modelees. In this way, role modeling effectively enhances the transformation of the student to a doctor.

Professionalism and ethics: A proposed curriculum for undergraduates

Professionalism is the attributes, behaviors, commitments, values, and goals that characterize a profession. In medical professional, it encompasses strong societal role and involves emotional component too. On the other hand, ethics is the study of morality – careful and systematic analysis of moral decisions and behaviors and practicing those decisions. Medical ethics focuses primarily on issues arising out of the practice of medicine. It is generally believed that professionalism and ethics are caught by watching your teachers and seniors and not taught formally. Professionalism and ethics are previously diffused passively to the students through “the hidden curriculum,” leaving a lot to chance. However, over the time, it has been advocated that graduates need to be formally trained in the concepts of professionalism and ethics. In this paper, we propose a formal curriculum on professionalism and ethics, tailor-made for Indian medical graduates.

Attributes of a good nurse

Background:

The opinions of students regarding the attributes of a good nurse can make a major contribution to the planning and the conducting of professional education. There are few studies which aim at identifying the qualifications of a good nurse from the perspectives of nursing students.

Objectives:

To determine the opinions of first- and fourth-year nursing students concerning the ‘attributes of a good nurse’, and whether and how their views change depending on their year of study.

Research design:

Descriptive research.

Participants and research context:

This study was conducted in the nursing department of a vocational school of health in the 2010/2011 academic year. The study participants consisted of first-year and intern students. A survey form was used to identify characteristics of participants, and students were asked the following open-ended question about their opinions related to the attributes of a good nurse.

Ethical considerations:

The permission was taken from the school administration. Informed consent was obtained, and anonymity was ensured for participating students.

Findings:

A total of 120 students participated in this study. Most frequently expressed attributes were ‘professional competence’ in first-year and ‘responsibility’ in fourth-year students. While first-year students placed a greater emphasis on the attributes of ‘geniality’, ‘patience’, ‘calmness’, ‘love of nursing’, ‘loyalty to nursing’ and ‘not attaching importance to material values’, fourth-year students emphasized the attributes of ‘empathy’, ‘honesty’, ‘responsibility’ and ‘scientific curiosity’ significantly more.

Discussion and conclusion:

Fourth-year students placed a greater emphasis on the attributes which the students are expected to acquire through a nursing program and clinical experience. However, they mentioned the attributes related to a good nurse–patient relationship and communication significantly less. Appropriate ethical training methods and good role models can help students acquire attributes that are important for the nursing profession and combine them with the attributes they already have.

Developing a patient focussed professional identity: an exploratory investigation of medical students' encounters with patient partnership in learning

Patient encounters are central to the provision of learning opportunities for medical students and their development as medical professionals. The primary aim of the study reported in this paper was to discover how partnering medical students with patients with chronic illness in undergraduate learning influenced the development of a patient centred professional identity and professionalism. An exploratory interpretive research design was used to address the research aim within a patient partner program (P3). Three qualitative data collection methods were used: (1) focus groups (2) extended response questionnaire and (3) semi-structured interviews. Data were coded and analysed thematically. The professional identity of medical students is constructed along traditional lines in the preclinical years. Patient-partnership offers a disruption to this development by way of an intersection with patients with chronic illness which potentially allows meaningful construction of what a patient-centred identity should be. This point of reflection provides an opportunity to engage at a higher level in medical identity development and professionalism. The findings discussed in this paper further stimulate the patient-centred agenda by understanding the conflict associated with the student-patient nexus in medical education and its potential for building professionalism and a patient-centred professional identity. To continue the drive for a patient-centred professional identity there must be ongoing engagement with patients in medical education, preferably commencing early in a student's journey so that it becomes the expected norm. This study has highlighted that a true patient-centred emphasis is being encountered too late in their socialisation process.

Organizational philosophy as a new perspective on understanding the learning of professionalism

OBJECTIVE

To define the concept of "organizational philosophy" through identification of elements within undergraduate pharmacy curricula in the United Kingdom that contribute to students' learning of professionalism.

METHODS

A qualitative study using curriculum mapping was conducted to identify "intended," "taught," and "received" curriculum in 3 schools of pharmacy. The study involved review of course materials, interviews with teaching staff members, focus groups with final year students, and observation of classes.

RESULTS

"Organizational philosophy" (totality of all contributors) played a vital part in students' professionalism learning. Key contributions were not restricted to the "taught" curriculum but extended to the wider academic environment. Setting of high standards appeared important; role models had particular significance. Importance of professionalism learning being grounded and longitudinal throughout the curriculum was highlighted. An "integrated" organizational philosophy appeared to be achieved where maximum overlap occurred between "intended," "taught," and "received" curricula.

CONCLUSIONS

Professionalism learning goes beyond the "taught" curriculum in pharmacy schools. The concept of "organizational philosophy" acknowledges the importance of integration between "intended," "taught," and "received" curriculum in the context of overall organization.

Doctor role modelling in medical education: BEME Guide No. 27

AIM

The aim of this review is to summarise the evidence currently available on role modelling by doctors in medical education.

METHODS

A systematic search of electronic databases was conducted (PubMed, Psyc- Info, Embase, Education Research Complete, Web of Knowledge, ERIC and British Education Index) from January 1990 to February 2012. Data extraction was completed by two independent reviewers and included a quality assessment of each paper. A thematic analysis was conducted on all the included papers.

RESULTS

Thirty-nine studies fulfilled the inclusion criteria for the review. Six main themes emerged from the content of high and medium quality papers: 1) the attributes of positive doctor role models; 2) the personality profiles of positive role models; 3) the influence of positive role models on students' career choice; 4) the process of positive role modelling; 5) the influence of negative role modelling; 6) the influence of culture, diversity and gender in the choice of role model.

CONCLUSIONS

This systematic review highlights role modelling as an important process for the professional development of learners. Excellence in role modelling involves demonstration of high standards of clinical competence, excellence in clinical teaching skills and humanistic personal qualities. Positive role models not only help to shape the professional development of our future physicians, they also influence their career choices. This review has highlighted two main challenges in doctor role modelling: the first challenge lies in our lack of understanding of the complex phenomenon of role modelling. Second, the literature draws attention to negative role modelling and this negative influence requires deeper exploration to identify ways to mitigate adverse effects. This BEME review offers a preliminary guide to future discovery and progress in the area of doctor role modelling.

Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25

INTRODUCTION

We undertook a systematic review to identify the best evidence for how professionalism in medicine should be taught.

METHODS

Eligible studies included any articles published between 1999 and 2009 inclusive. We reviewed papers presenting viewpoints and opinions as well as empirical research. We performed a comparative and thematic synthesis on all papers meeting inclusion criteria in order to capture the best available evidence on how to teach professionalism.

RESULTS

We identified 217 papers on how to teach professionalism. Of these, we determined 43 to be best evidence. Few studies provided comprehensive evaluation or assessment data demonstrating success. As yet, there has not emerged a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum.

DISCUSSION

Evident themes in the literature are that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programmes, and are widely held to be the most effective techniques for developing professionalism. While it is generally held that professionalism should be part of the whole of a medical curriculum, the specifics of sequence, depth, detail, and the nature of how to integrate professionalism with other curriculum elements remain matters of evolving theory.

Teaching and assessing veterinary professionalism

The teaching and assessment of professional behaviors and attitudes are important components of veterinary curricula. This article aims to outline some important considerations and concepts which will be useful for veterinary educators reviewing or developing this topic. A definition or framework of veterinary professionalism must be decided upon before educators can develop relevant learning outcomes. The interface between ethics and professionalism should be considered, and both clinicians and ethicists should deliver professionalism teaching. The influence of the hidden curriculum on student development as professionals should also be discussed during curriculum planning because it has the potential to undermine a formal curriculum of professionalism. There are several learning theories that have relevance to the teaching and learning of professionalism; situated learning theory, social cognitive theory, adult learning theory, reflective practice and experiential learning, and social constructivism must all be considered as a curriculum is designed. Delivery methods to teach professionalism are diverse, but the teaching of reflective skills and the use of early clinical experience to deliver valid learning opportunities are essential. Curricula should be longitudinal and integrated with other aspects of teaching and learning. Professionalism should also be assessed, and a wide range of methods have the potential to do so, including multisource feedback and portfolios. Validity, reliability, and feasibility are all important considerations. The above outlined approach to the teaching and assessment of professionalism will help ensure that institutions produce graduates who are ready for the workplace.

Students meeting with caregivers of cancer patient: results of an experience-based learning project

The communication between medical students and cancer caregivers, and the problems they have experienced as well as the outcomes for their professional development before starting clinical practice was assessed in the context of a student research project. Data were collected by questionnaires or by 20 to 40-min long interviews with cancer caregivers. Their communications with physicians, hearing the bad news, and health service satisfaction were questioned. Therefore, the caregivers trusted the professional approach of their physician. However, they expected more empathic communication in the process of diagnosis and therapy. Development of empathy and trust-based communication between patients and physicians and enhancement of the quality of devoted time to cancer patients and caregivers may have an effect on the course of disease. Interviewer students mentioned that they developed communication skills about difficult clinical tasks and in delivering bad news face to face to cancer caregivers before starting their clinical education.

Medical students' perceptions of the factors influencing their academic performance: an exploratory interview study with high-achieving and re-sitting medical students

BACKGROUND

Little is known about medical students' perceptions of the factors that influence their academic performance.

AIM

To detect factors medical students, in the final years of their undergraduate medical studies, believe affect their academic performance.

METHODS

We conducted semi-structured interviews with high-achieving and re-sitting students in the final two years of their studies in a London medical school. Interviews were recorded and transcribed. Thematic content analysis was conducted. Similarities and differences in factors perceived to affect the academic performance of high-achieving and re-sitting students were identified.

RESULTS

Eight re-sitting and ten high-achieving students were interviewed. Three core themes were identified: engagement with learning; reflections on learning methods and experiences and the application of learning to future practice. High-achieving students showed a greater awareness of what worked in terms of their approaches to learning and coping with difficulty than re-sitting students. There were also differences in the degree of positive engagement with peers, suggesting the positive contribution of socialising with other medical students.

CONCLUSIONS

This exploratory qualitative study identified attitudes, behaviours and motivations that appeared to contribute to success or failure at medical school. Our findings suggest ways to improve appraisal, remediation and support mechanisms for students.

How do pharmacy students learn professionalism?

OBJECTIVE

To understand and clarify how professionalism is learnt, cultivated and facilitated in pharmacy education.

METHODS

Qualitative methodology involving three UK schools of pharmacy was used, including documentary analysis of course materials, interviews with seven teaching staff, six focus groups with 38 final-year pharmacy students and observation of professional pharmacy practice classes. We used a 'curriculum mapping' framework; analysis was thematic, with triangulation of methods and constant comparison between groups of participants and schools.

KEY FINDINGS

Students and teachers found defining professionalism difficult, but they identified common attitudinal and behavioural attributes. These were predominantly based on students' work experience, and role models were identified as particularly influential. Professionalism learning needed to be grounded and longitudinal throughout the curriculum. Practical classes and the use of real-life examples and role plays were influential; and teacher practitioners appeared particularly valuable due to their dual base in practice. Explicit statements in year books and codes of conduct were valuable, especially if they were reinforced and carried through.

CONCLUSIONS

This study offers novel insights into professionalism learning during undergraduate education in the UK, by triangulating evidence from different sources and perspectives. It not only underpins the importance of professionalism learning but also highlights approaches which appeared valuable within the constraints of an otherwise artificial university environment.

Patient rights and medical education: clinical principles

The rights of patients may be considered within three broad categories: (i) health as a fundamental human right, (ii) equitable healthcare provision by governments and institutions, and (iii) professional relationships with individual health practitioners. Doctors should be well prepared in medical schools to understand and uphold patient rights. A simplified framework for learning and for teaching medical students about patient rights is proposed with the acronym DROIT--dignity, respect, obligation, information and trust.

Medical professionalism: conflicting values for tomorrow's doctors

BACKGROUND

New values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation.

OBJECTIVE

To investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum.

METHODS

Qualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care.

RESULTS

Professional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the 'old' model of professionalism that had not be directly taught to them. Integrating 'new' professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them.

CONCLUSIONS

The conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that 'new' models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.

New fitness-to-practice requirements for pharmacists in Ireland: implications for undergraduate pharmacy education

Internationally, there is tighter monitoring and enforcement of fitness-to-practice requirements in healthcare, which are being specified within legislation and guidelines. In Ireland, the Pharmacy Act 2007, that was recently published and is being gradually implemented, includes a provision for monitoring fitness-to-practice of pharmacists practicing here. This will mean that upon initial and continued registration by the Council of the Pharmaceutical Society of Ireland, pharmacists must satisfy a fitness-to-practice committee. Two routes by which a pharmacist can be deemed unfit to practice are specified within the Act - on the basis of ill health and through technical incompetence/malice. However, the exact nature of professional, cultural, and technical competencies required to satisfy these new fitness-to-practice requirements remain undecided and a further consultation with all stakeholders is required. Importantly, this consultative process must consider current practice standards and raise awareness of these issues among pharmacists while also considering the current and future undergraduate pharmacy students, i.e. the future pharmacists of Ireland. Radical cultural shifts in monitoring fitness-to-practice, with full professional accountability, must inform changes in the undergraduate curriculum and in assessing students, such that when they graduate, they are thoroughly prepared for ongoing fitness-to-practice scrutiny. Here, different approaches to international pharmacy education that may help pharmacy educators in Ireland prepare their students for the new fitness-to-practice requirements are reviewed and discussed.

Twelve tips to designing and implementing a learner-centred curriculum: prevention is better than cure

BACKGROUND

Change in medical education has brought with it new perspectives on content, process, assessment and evaluation. With this change has emerged a new discourse. New words and phrases, used by many but not always fully understood, have infiltrated every aspect of our academic lives. One such term which we believe is used relatively freely but which is not well understood or implemented is "learnercentred" or "student-centred" education.

AIM

These twelve tips, drawn from experience, attempt to clarify the implications of learner-centred education and provide a structure upon which to ensure that all stakeholders have the same understanding of the implications of what being learn-centredness involves.

CONCLUSIONS

Without a common understanding of learner-centreness, the true educational concept may not be appropriately implemented, resulting in considerable faculty and student stress. We should practice what we preach and consider the "whole" student.

Assessment of medical professionalism: who, what, when, where, how, and ... why?

Medical professionalism is increasingly recognized as a core competence of medical trainees and practitioners. Although the general and specific domains of professionalism are thoroughly characterized, procedures for assessing them are not well-developed. This article outlines an approach to designing and implementing an assessment program for medical professionalism that begins and ends with asking and answering a series of critical questions about the purpose and nature of the program. The process of exposing an assessment program to a series of interrogatives that comprise an integrated and iterative framework for thinking about the assessment process should lead to continued improvement in the quality and defensibility of that program.