Professionalism: a framework to guide medical education

Promoting professionalism through humanities-based transformation

INTRODUCTION

In the last two decades, academic medical centers in the United States have faced a new challenge, dealing with breaches of medical professionalism in their staff, house staff, and medical students. Medical education settings have largely directed their professionalism efforts toward responding reactively to negative outliers.

DISCUSSION

This paper contends that the warrant of medical education mandates a transformative path forward. While negative behavior must be responded to meaningfully, so, too, must positive role models of professional behavior be publicly lauded for their consequential culture change in their institutions, and promoted as positive role models. Further, the promotion of medical professionalism must be part of this culture by proactively engaging all learners and health care providers with medical ethics and humanities-based knowledge, critical thinking skills, and role modeling.

CONCLUSION

Professionalism programs should be vested with the authority to implement an affirmative educational program intended to nurture and promote medical professionalism in each medical student, resident, fellow, and attending and utilize methods to that end employing both virtue and care ethics.

Impact of group work on the hidden curriculum that induces students' unprofessional behavior toward faculty

BACKGROUND

Hidden curriculum (HC) can limit the effects of professionalism education. However, the research on how HC triggers unprofessional behavior among medical students is scant. Furthermore, there is no established approach for how faculty members may create a context, such as an educational environment and education system, that prevents students' unprofessional behavior. This study aimed to develop an educational approach to prevent unprofessional behavior and clarify how faculty members consider HC that triggers students' unprofessional behavior.

METHODS

The study sample comprised 44 faculty members and eight medical students from the Chiba University School of Medicine. The participants were divided into groups and asked the following question: "What attitudes, statements, and behaviors of senior students, physicians, and faculty members trigger medical students' unprofessional behavior?" The responses were collected using the affinity diagram method. The group members discussed the causes and countermeasures for the selected attitudes, statements, and behaviors of senior students, physicians, and faculty members based on the affinity diagram. The impact of the group work on the faculty members was surveyed using questionnaires immediately after its completion and six months later. Furthermore, the cards in the group work were analyzed using content analysis.

RESULTS

The responses to the questionnaire on group work indicated that some faculty members (43.8%) improved HC, while others suggested conducting group work with more participants. The content analysis revealed six categories - inappropriate attitude/behavior, behavior encouraging unprofessional behavior, lack of compliance with regulations, harassment of other medical staff, inappropriate educational environment/supervisor, and inappropriate self-control - and 46 subcategories.

CONCLUSIONS

The HC that triggers students' unprofessional behavior includes the words and actions of the educator, organizational culture, and educational environment. Group work makes faculty members aware of the HC that triggers unprofessional behavior, and induces behavioral change for HC improvement in the educational activities. Educators should refrain from using words and actions that encourage unprofessional behavior, such as personal anecdotes, as they reduce students' learning motivation.

Mentoring as a complex adaptive system - a systematic scoping review of prevailing mentoring theories in medical education

BACKGROUND

Effective mentorship is an important component of medical education with benefits to all stakeholders. In recent years, conceptualization of mentorship has gone beyond the traditional dyadic experienced mentor-novice mentee relationship to include group and peer mentoring. Existing theories of mentorship do not recognize mentoring's personalized, evolving, goal-driven, and context-specific nature. Evidencing the limitations of traditional cause-and-effect concepts, the purpose of this review was to systematically search the literature to determine if mentoring can be viewed as a complex adaptive system (CAS).

METHODS

A systematic scoping review using Krishna's Systematic Evidence-Based Approach was employed to study medical student and resident accounts of mentoring and CAS in general internal medicine and related subspecialties in articles published between 1 January 2000 and 31 December 2023 in PubMed, Embase, PsycINFO, ERIC, Google Scholar, and Scopus databases. The included articles underwent thematic and content analysis, with the themes identified and combined to create domains, which framed the discussion.

RESULTS

Of 5,704 abstracts reviewed, 134 full-text articles were evaluated, and 216 articles were included. The domains described how mentoring relationships and mentoring approaches embody characteristics of CAS and that mentorship often behaves as a community of practice (CoP). Mentoring's CAS-like features are displayed through CoPs, with distinct boundaries, a spiral mentoring trajectory, and longitudinal mentoring support and assessment processes.

CONCLUSION

Recognizing mentorship as a CAS demands the rethinking of the design, support, assessment, and oversight of mentorship and the role of mentors. Further study is required to better assess the mentoring process and to provide optimal training and support to mentors.

Assessing professional behaviors: a self-administered scale for medical students during clerkships

BACKGROUND

Medical professionalism is a core competency for medical students during clerkships for further professional development. Given that the behavior-based framework could provide clear insight and is easy to assess, the study aimed to create a self-administered scale to measure the professional behaviors of medical students during their clerkships.

METHODS

A comprehensive literature review on medical professional behaviors in English or Chinese and Delphi interviews were used to develop the initial version of the Self-Administered Scale for Professional Behavior of Medical Students During Clerkships. The reliability and validity analysis based on a survey of medical students from China, Cronbach's α calculations, and Confirmatory Factor Analysis (CFA) specifically were conducted to finalize the scale. The associations of professional behaviors with gender, medical programs, and clerkship duration were examined using Wilcoxon rank-sum tests.

RESULTS

We included 121 studies and extracted 57 medical professionalism assessment tools, initially forming a pool of 48 items. To refine these items, eighteen experts participated in two rounds of Delphi interviews, ultimately narrowing down the item pool to 24 items. A total of 492 participants effectively completed the questionnaire. One item was removed due to its correlated item-total correlation (CITC) value, resulting in a final scale containing 23 items with six domains: Respect, Altruism, Communication and Collaboration, Integrity, Duty, and Excellence. The overall Cronbach's alpha value was 0.98, ranging from 0.88 to 0.95 for each domain. The fit indices (χ2/df = 4.07, CFI = 0.96, TLI = 0.95, RMSEA = 0.08, and SRMR = 0.02) signified a good fit for the six-domain model. Medical students' professional behavior was significantly associated with gender (p = 0.03) and clerkship duration (p = 0.001).

CONCLUSION

The scale was demonstrated to be reliable and valid in assessing the professional behaviors of Chinese medical students during clerkships.

Professional Identity Formation in Medical Education: Some Virtue-Based Insights

Issue: In 2010, the Carnegie Foundation published a call to reorient medical education in terms of the formation of identities rather than mere competencies, and the medical education literature on professional identity formation (PIF) has since grown rapidly. As medical learners navigate a hectic clinical learning environment fraught with challenges to professionalism and ethics, they must simultaneously orient their skills, behaviors, and evolving sense of professional identity. The medical education literature on PIF describes the psychosocial dimensions of that identity formation well. However, in its conceptual formulations, the literature risks underappreciating the pedagogical significance of the moral basis of identity formation-that is, the developing moral agencies and aspirations of learners to be good physicians. Evidence: Our conceptual analysis and argument build on a critical review of the medical education literature on PIF and draw on relevant insights from virtue ethics to deepen the conceptualization of PIF in moral, and not just psychosocial, terms. We show that a narrowly psychosocial view risks perpetuating institutional perceptions that can conceive professionalism norms primarily as standards of discipline or social control. By drawing on the conceptual resources of virtue ethics, we highlight not just the psychosocial development of medical learners but also their self-reflective, critical development as particular moral agents aspiring to embody the excellences of a good physician and, ultimately, to exhibit those traits and behaviors in the practice of medicine. Implications: We consider the pedagogical relevance of this insight. We show that drawing on virtue theory can more adequately orient medical pedagogy to socialize learners into the medical community in ways that nurture their personal growth as moral agents-in terms of their particular, restless aspirations to be a good physician and to flourish as such.

Should we add patients in concordance of judgment learning tool panels? - An analysis between patients and primary care physicians

INTRODUCTION

The Concordance of Judgment Learning Tool (CJLT) has been developed for distance asynchronous learning of professionalism in health sciences education. The learning of professionalism is induced by a student's comparison of their own responses with those of the panel members. Whilst CJLT programs typically include same profession experts in their panels, we believe that they could also include patients. Accordingly, we conducted a study aimed at comparing CJLT response patterns between two groups of primary care physicians (PCPs) and patients.

METHODS

We conducted a mixed prospective study of responses to a CJLT program based on a group of PCPs and a group of patients: an analysis of the response patterns of the two groups and a qualitative analysis of justifications.

RESULTS

A total of 110 participants were included in the study: 70 patients and 40 PCPs. We found a significant difference in response patterns between the PCP and patient groups for nine of the fifteen questions (60%). The qualitative analysis of justifications between groups allowed us to comprehend patients' views on the professionalism of PCPs.

CONCLUSIONS

Including patients in CJLT panels can enrich the feedback offered to students in these online training programs.

Storylines of family medicine XI: professional identity formation-nurturing one's own story

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XI: professional identity formation-nurturing one's own story', authors address the following themes: 'The social construction of professional identity', 'On becoming a family physician', 'What's on the test?-professionalism for family physicians', 'The ugly doc-ling', 'Teachers-the essence of who we are', 'Family medicine research-it starts in the clinic', 'Socially accountability in medical education', 'Personal philosophy and how to find it' and 'Teaching and learning with Storylines of Family Medicine'. May these essays encourage readers to find their own creative spark in medicine.

Impacts of early clinical exposure on undergraduate student professionalism-a qualitative study

INTRODUCTION

Early clinical exposure (ECE), or authentic human contact in a social or clinical context during preclinical training, has been adopted by many medical schools. This study aims to investigate how medical students' sense of professionalism changed after ECE intervention, with the aim of informing curriculum design to enhance student awareness of the importance of medical professionalism.

METHOD

Focus groups of ECE students were held to collect data for the study. All participants read interview guidelines before starting. During the focus groups, the students discussed their medical obligations as perceived throughout the course, which offered a choice between four different ECE tracks. They were then asked to report their understanding of the situations they encountered during the course and reflect on their implications.

RESULTS

Six focus groups of 22 students in total from a medical school in northern Taiwan were held shortly after the students completed an ECE course in September 2019. From their responses, 10 categories relating to medical professionalism were deduced categorized under 5 major dimensions. An additional 8 sub-dimensions on attitudes and 2 sub-dimensions on personal well-being were also identified as new categories separate from but related to medical professionalism. After the ECE intervention, about 59% of participants redefined their understanding of medical professionalism.

CONCLUSION

ECE and intensive interaction with key stakeholders, including patients and their families, help students in the early stages of medical education form and cultivate a sense of medical professionalism. However, the relationship between participants' personalities, motivations, and clinical activities requires further investigation.

Associations between admissions factors and the need for remediation

This study examines the way in which student characteristics and pre-admissions measures are statistically associated with the likelihood a student will require remediation for academic and professionalism offenses. We anchor our inquiry within Irby and Hamstra's (2016) conceptual framework of constructs of professionalism. Data from five graduating cohorts (2014-2018) from McMaster University (Hamilton, Canada) (N = 1,021) were retroactively collected and analyzed using traditional and multinominal logistic regression analyses. The relationship among student characteristics, pre-admissions variables, and referral for potential remediation both by occurrence (yes/no) as well as type (academic/professional/no referral) were examined separately. Findings indicate that gender (OR = 0.519, 95% CI 0.326-0.827, p < 0.01) and undergraduate grade point average (GPA) (OR = 0.245, 95% CI 0.070-0.855, p < 0.05) were significantly associated with instances of referral for potential professionalism and academic remediation, respectively. Women were less likely than men to require remediation for professionalism (OR = 0.332, 95% CI 0.174-0.602, p < 0.001). Undergraduate GPAs (OR = 0.826, 95% CI 0.021-0.539, p < 0.01) were significantly associated with remediation for academic reasons. Lower undergraduate GPAs were associated with a higher likelihood of remediation. These findings point to the admissions variables that are associated with instances that prompt referral for potential remediation. Where associations are not significant, we consider the application of different conceptualizations of professionalism across periods of admissions and training. We encourage those involved in applicant selection and student remediation to emphasize the importance of the interactions that occur between personal and contextual factors to influence learner behaviour and professional identity formation.

Virtue and care ethics & humanism in medical education: a scoping review

PURPOSE

This scoping review explores how virtue and care ethics are incorporated into health professions education and how these factors may relate to the development of humanistic patient care.

METHOD

Our team identified citations in the literature emphasizing virtue ethics and care ethics (in PubMed, NLM Catalog, WorldCat, EthicsShare, EthxWeb, Globethics.net , Philosopher's Index, and ProQuest Central) lending themselves to constructs of humanism curricula. Our exclusion criteria consisted of non-English articles, those not addressing virtue and care ethics and humanism in medical pedagogy, and those not addressing aspects of character in health ethics. We examined in a stepwise fashion whether citations: 1) Contained definitions of virtue and care ethics; 2) Implemented virtue and care ethics in health care curricula; and 3) Evidenced patient-directed caregiver humanism.

RESULTS

Eight hundred eleven citations were identified, 88 intensively reviewed, and the final 25 analyzed in-depth. We identified multiple key themes with relevant metaphors associated with virtue/care ethics, curricula, and humanism education.

CONCLUSIONS

This research sought to better understand how virtue and care ethics can potentially promote humanism and identified themes that facilitate and impede this mission.

Confronting the Hidden Curriculum: A Four-Year Integrated Course in Ethics and Professionalism Grounded in Virtue Ethics

We describe a virtue ethics approach and its application in a four-year, integrated, longitudinal, and required undergraduate medical education course that attempts to address some of the challenges of the hidden curriculum and minimize some of its adverse effects on learners. We discuss how a curriculum grounded in virtue ethics strives to have the practical effect of allowing students to focus on their professional identity as physicians in training rather than merely on knowledge and skills acquisition. This orientation, combined with a student-generated curriculum, is designed to prepare students to identify and face challenges during their clinical years, further nurturing their professional growth. In short, a four-year integrated ethics and professionalism curriculum intentionally centered on cultivating virtuous physicians may alleviate, and even counteract, the effects of the hidden curriculum in the clinical years of medical training.

Medical Education e-Professionalism (MEeP) framework; from conception to development

BACKGROUND

Medical professionalism education intends to produce virtuous and humanistic healthcare professionals who demonstrate perseverance and professional integrity. However, today's medicine has embodied a mammoth transformation of medical practice towards sns and the digital realm. Such paradigm shift has challenged the medical professional's values, behaviors, and identities, and the distinct boundaries between personal and professional lives are blurred. This study aims to develop a framework for healthcare professionals coping with the challenges of medical professionalism in the digital realm.

METHODS

We followed a systematic approach for the development of a framework about e-professionalism. Qualitative data was collected from a systematic review and a delphi study, while quantitative data was collected by administering a validated questionnaire social networking sites for medical education (snsme). Subsequently, categorization of the selected data and identifying concepts, deconstruction and further categorizing concepts (philosophical triangulation), integration of concepts (theoretical triangulation), and synthesis and resynthesis of concepts were performed.

RESULTS

The initial process yielded six overlapping concepts from personal, professional, character (implicit) and characteristic (explicit) domains: environment, behavior, competence, virtues, identity, and mission. Further integration of data was done for the development of the medical education e-professionalism (meep) framework with a central concept of a commitment to mission. The mission showed deep connections with values (conformity, beneficence, universalism, and integrity), behaviours (communication, self-awareness, tolerance, power), and identity (reflection, conscientiousness, self-directed, self-actualization). The data demonstrated that all medical professionals require updated expertise in sns participation.

CONCLUSION

The meep framework recognises a mission-based social contract by the medical community. This mission is largely driven by professional values, behaviors and identity. Adherence to digital standards, accountability, empathy, sensitivity, and commitment to society are essential elements of the meep framework.

Medical educators' beliefs about teaching, learning, and knowledge: development of a new framework

BACKGROUND

The educational beliefs of medical educators influence their teaching practices. Insight into these beliefs is important for medical schools to improve the quality of education they provide students and to guide faculty development. Several studies in the field of higher education have explored the educational beliefs of educators, resulting in classifications that provide a structural basis for diverse beliefs. However, few classification studies have been conducted in the field of medical education. We propose a framework that describes faculty beliefs about teaching, learning, and knowledge which is specifically adapted to the medical education context. The proposed framework describes a matrix in which educational beliefs are organised two dimensionally into belief orientations and belief dimensions. The belief orientations range from teaching-centred to learning-centred; the belief dimensions represent qualitatively distinct aspects of beliefs, such as 'desired learning outcomes' and 'students' motivation'.

METHODS

We conducted in-depth semi-structured interviews with 26 faculty members, all of whom were deeply involved in teaching, from two prominent medical schools. We used the original framework of Samuelowicz and Bain as a starting point for context-specific adaptation. The qualitative analysis consisted of relating relevant interview fragments to the Samuelowicz and Bain framework, while remaining open to potentially new beliefs identified during the interviews. A range of strategies were employed to ensure the quality of the results.

RESULTS

We identified a new belief dimension and adapted or refined other dimensions to apply in the context of medical education. The belief orientations that have counterparts in the original Samuelowicz and Bain framework are described more precisely in the new framework. The new framework sharpens the boundary between teaching-centred and learning-centred belief orientations.

CONCLUSIONS

Our findings confirm the relevance of the structure of the original Samuelowicz and Bain beliefs framework. However, multiple adaptations and refinements were necessary to align the framework to the context of medical education. The refined belief dimensions and belief orientations enable a comprehensive description of the educational beliefs of medical educators. With these adaptations, the new framework provides a contemporary instrument to improve medical education and potentially assist in faculty development of medical educators.

Exploring the use of virtues to facilitate identity construction among management students

This paper explores the challenges and opportunities facing educators who wish to facilitate management students' identity construction as a means to foster their students' emergent professional identities and post-graduate career attainments. We look to medical and law schools' recent advancements, alongside their traditional dissemination of knowledge and technical skills, in better aligning students' developing identities and related behaviors with respective professional ideals. Drawing on insights from these professional schools, we examine whether the concept of "professional virtues" that's proven valuable in these contexts might also be used to facilitate students' professional identity construction within management education.

"Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation

BACKGROUND

Efforts have begun to characterize the ethical and professional issues encountered by medical students in their clinical years. By applying previously identified taxonomies to a national sample of medical students, this study seeks to develop generalizable insights that can inform professional identity formation across various clerkships and medical institutions.

METHODS

In a national survey of medical students, participants answered an open-ended survey item that asked them to describe a clinical experience involving an ethical or professional issue. We conducted a content analysis with these responses using the Kaldjian taxonomy of ethical and professionalism themes in medical education through an iterative, consensus-building process. Noting the emerging virtues-based approach to ethics and professionalism, we also reexamined the data using a taxonomy of virtues.

RESULTS

The response rate to this survey item was 144 out of 499 eligible respondents (28.9%). All 144 responses were successfully coded under one or more themes in the original taxonomy of ethical and professional issues, resulting in a total of 173 coded responses. Professional duties was the most frequently coded theme (29.2%), followed by Communication (26.4%), Quality of care (18.8%), Student-specific issues of moral distress (16.7%), Decisions regarding treatment (16.0%), and Justice (13.2%). In the virtues taxonomy, 180 total responses were coded from the 144 original responses, and the most frequent virtue coded was Wisdom (23.6%), followed by Respectfulness (20.1%) and Compassion or Empathy (13.9%).

CONCLUSIONS

Originally developed from students' clinical experiences in one institution, the Kaldjian taxonomy appears to serve as a useful analytical framework for categorizing a variety of clinical experiences faced by a national sample of medical students. This study also supports the development of virtue-based programs that focus on cultivating the virtue of wisdom in the practice of medicine.

Medical Ethics: Common or Uncommon Morality?

This paper challenges the long-standing and widely accepted view that medical ethics is nothing more than common morality applied to clinical matters. It argues against Tom Beauchamp and James Childress's four principles; Bernard Gert, K. Danner Clouser and Charles Culver's ten rules; and Albert Jonsen, Mark Siegler, and William Winslade's four topics approaches to medical ethics. First, a negative argument shows that common morality does not provide an account of medical ethics and then a positive argument demonstrates why the medical profession requires its own distinctive ethics. The paper also provides a way to distinguish roles and professions and an account of the distinctive duties of medical ethics. It concludes by emphasizing ways in which the uncommon morality approach to medical ethics is markedly different from the common morality approach.

Professional values and behaviours of younger and older general practitioners in Scotland: a cross-sectional survey

Aim

Professionalism has been linked with improved patient care and reduced complaints. Our goal was to define what, if any, differences exist in the professional values and behaviours of younger general practitioners (GPs), those aged 34 years and under, compared with their older colleagues, those being aged 55 years and over.

Method

An online cross-sectional questionnaire survey of GPs in Scotland was undertaken during 2018 using a modified version of the Nijmegen Professionalism Scale, which comprises 4 domains: professionalism towards patients, towards colleagues, towards society and towards oneself. Descriptive and inferential data analysis was undertaken between responses from both GP groups.

Results

273 responses were obtained. Of these, 106 respondents were classed as either younger GPs (n=55; 51.9%) or older (n=51; 48.1%). The greatest number of differences were found in the Professional Distance subsection of professionalism towards patients. The greatest single disparity in responses was to distinguish between personal and professional interests in negotiations (p<0.0001). Younger GPs also reported they were less likely to bear the consequences of their own actions (p<0.02) and to be more likely to give others the blame or responsibility (p<0.006). Younger GPs report being less skilled in quality management, being less able to signal suboptimal care (p<0.006) and justify indications for making home visits (p<0.001).

Conclusion

While there were areas of similarity in relation to collaborating with colleagues, reflection on learning and dealing with emotions, differences were identified in relation to the 5 other subsections. Some differences may be explained by lack of exposure and experience, but this may not account for all the differences reported.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND

Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs.

METHODS

We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries.

RESULTS

Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education.

CONCLUSIONS

In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Professional decision-making in medicine: Development of a new measure and preliminary evidence of validity

Introduction

This study developed a new Professional Decision-Making in Medicine Measure that assesses the use of effective decision-making strategies: seek help, manage emotions, recognize consequences and rules, and test assumptions and motives. The aim was to develop a content valid measure and obtain initial evidence for construct validity so that the measure could be used in future research or educational assessment.

Methods

Clinical scenario-based items were developed based on a review of the literature and interviews with physicians. For each item, respondents are tasked with selecting two responses (out of six plausible options) that they would choose in that situation. Three of the six options reflect a decision-making strategy; these responses are scored as correct. Data were collected from a sample of 318 fourth-year medical students in the United States. They completed a 16-item version of the measure (Form A) and measures of social desirability, moral disengagement, and professionalism attitudes. Professionalism ratings from clerkships were also obtained. A sub-group (n = 63) completed a second 16-item measure (Form B) to pilot test the instrument, as two test forms are useful for pre-posttest designs.

Results

Scores on the new measure indicated that, on average, participants answered 75% of items correctly. Evidence for construct validity included the lack of correlation between scores on the measure and socially desirable responding, negative correlation with moral disengagement, and modest to low correlations with professionalism attitudes. A positive correlation was observed with a clerkship rating focused on professionalism in peer interactions.

Conclusions

These findings demonstrate modest proficiency in the use of decision-making strategies among fourth-year medical students. Additional research using the Professional Decision-Making Measure should explore scores among physicians in various career stages, and the causes and correlates of scores. Educators could utilize the measure to assess courses that teach decision-making strategies.

Conscience, conscientious objections, and medicine

To inform the ongoing discussion of whether claims of conscientious objection allow medical professionals to refuse to perform tasks that would otherwise be their duty, this paper begins with a review of the philosophical literature that describes conscience as either a moral sense or the dictate of reason. Even though authors have starkly different views on what conscience is, advocates of both approaches agree that conscience should be obeyed and that keeping promises is a conscience-given moral imperative. The paper then considers exemplars of conscientious objection-Henry David Thoreau, Mohandas Gandhi, and Martin Luther King Jr.-to identify the critical feature of conscientious objection as willingness to bear the burdens of one's convictions. It concludes by showing that medical professionals who put their own interests before their patients' welfare violate their previous commitments and misappropriate the title "conscientious objector" because they are unwilling to bear the burdens of their choices and instead impose burdens on their patients and colleagues.

Why not common morality?

This paper challenges the leading common morality accounts of medical ethics which hold that medical ethics is nothing but the ethics of everyday life applied to today's high-tech medicine. Using illustrative examples, the paper shows that neither the Beauchamp and Childress four-principle account of medical ethics nor the Gert et al 10-rule version is an adequate and appropriate guide for physicians' actions. By demonstrating that medical ethics is distinctly different from the ethics of everyday life and cannot be derived from it, the paper argues that medical professionals need a touchstone other than common morality for guiding their professional decisions. That conclusion implies that a new theory of medical ethics is needed to replace common morality as the standard for understanding how medical professionals should behave and what medical professionalism entails. En route to making this argument, the paper addresses fundamental issues that require clarification: what is a profession? how is a profession different from a role? how is medical ethics related to medical professionalism? The paper concludes with a preliminary sketch for a theory of medical ethics.

Pre-clerkship medical students' perceptions of medical professionalism

BACKGROUND

Professionalism instruction and assessment is a core component of medical education, and essential for professional identity formation (PIF). Thus, understanding the socialization of medical students to the values of the profession (i.e., medical professionalism), and how these may evolve, warrants continued understanding.

METHODS

The purpose of this study was to examine and compare pre-clerkship (first and second year) medical students' perceptions of professionalism. First and second year medical students participate in this study. This was a two-phase mixed-methods cohort study conducted across two academic years (2014-2015 and 2015-2016). In Phase I, first and second year medical students participated in a nominal group technique (NGT) session. NGT data was analyzed qualitatively to generate a card-sorting exercise of professionalism attributes for Phase II. In Phase II, data from the sorting task was analyzed using Principle Component Analysis (PCA).

RESULTS

The PCA for first year students derived a 7-factor solution. Factors (i.e., professionalism domains) identified were: Self-management and patient-centeredness, ethics and professional reputation, dependability, self-awareness and self-improvement, image, proficiency and lifelong learning and integrity. The PCA for second year students derived a 5-factor solution; factors identified were: "Good Doctor" attributes, responsibility, ethics, innovation and self-improvement and unbiased.

CONCLUSIONS

Identification and organization of attributes into an overarching professionalism mental model provide a window into the active reconstruction of students' professional identity during the nascent stages of medical education. M1 professionalism domains were more consistent with the conventional professional image of the physician (e.g. Ethics and Professional reputation, Dependability, Integrity), whereas, M2 domains reflected a more global view (e.g., "Good Doctor" attributes, Responsibility, Ethics). This study provides a lens into the dynamic nature of students' PIF and encourages educators to evaluate PIF pedagogy at their own institutions.

Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group

This article reports the consensus recommendations of a working group that was convened at the end of a 4-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and related matters. The working group recognized the need for further refinement of the recommendations to ensure feasibility and appropriate balance between protection of patients and fairness to physicians. While full implementation of appropriate measures will require time and study, we believe it is urgent to take visible actions to acknowledge and address the problem at hand.

Professionalism: An Archaeology

For more than two decades, classes on "professionalism" have been the dominant platform for the non-technical socialization of medical students. It thus subsumes elements of previous foundation courses in bioethics and "medicine and society" in defining the appropriate relation between practitioners, patients, and society-at-large. Despite its importance, there is, however, no clear definition of what "professionalism" entails or the manner in which it serves various purported goals. This essay reviews, first, the historical role of the vocational practitioner in society, and second, the introduction of "professionalism" as a newly constituted, core value in teaching. The structure of the paper is as an archaeology, a Foucauldian term for an investigation of seemingly separate but related antecedent contexts and ideas whose result is a perspective or point of view. The goal thus is an attempt to precisely locate "professionalism" within the greater history of medicine and its contemporary role in medical socialization.

Hypothesis: the hospital learning environment impedes students' acquisition of reflectivity and medical professionalism

Undergraduate clinical education follows the "bedside" tradition that exposes students to inpatients. However, the hospital learning environment has two main limitations. First, most inpatients require acute care, and students may complete their training without seeing patients with frequent non-emergent and chronic diseases that are managed in outpatient settings. Second, students rarely cope with diagnostic problems, because most inpatients are diagnosed in the community or the emergency room. These limitations have led some medical schools to offer longitudinal integrated clerkships in community settings instead of hospital block clerkship rotations. In this paper, I propose the hypothesis that the hospital learning environment has a third limitation: it causes students' distress and delays their development of reflectivity and medical professionalism. This hypothesis is supported by evidence that (a) the clinical learning environment, rather than students' personality traits, is the major driver of students' distress, and (b) the development of attributes, such as moral reasoning, empathy, emotional intelligence and tolerance of uncertainty that are included in the definitions of both reflectivity and medical professionalism, is arrested during undergraduate medical training. Future research may test the proposed hypothesis by comparing students' development of these attributes during clerkships in hospital wards with that during longitudinal clerkships in community settings.

Valeurs liées à la profession d’ergothérapeute : les répertorier pour les définir

Description.

Des imprécisions et des confusions conceptuelles caractérisent les écrits sur les valeurs liées à l’ergothérapie.

But.

Répertorier des valeurs liées à l’ergothérapie, proposer des énoncés qui les définissent et procéder à leur validation de contenu.

Méthodologie.

Une recension des écrits ( n = 52) et la consultation d’ergothérapeutes ( n = 26) ont permis de documenter et de définir une série de valeurs. Le répertoire issu de ces démarches a été soumis à un test de fonctionnalité auprès d’ergothérapeutes ( n = 5), puis présenté à des ergothérapeutes détenant une expertise en éthique ( n = 6) pour en évaluer la validité de contenu des définitions des valeurs.

Résultats.

Le répertoire proposé comprend 33 valeurs suivies de leur définition que les experts ont jugées claires et représentatives des réalités qu’elles désignent. Les résultats montrent que le répertoire est considéré comme exhaustif.

Conséquences.

Cette étude a permis de répertorier et de définir des valeurs qui constituent des idéaux susceptibles de guider la pratique ergothérapique et de soutenir les revendications ainsi que les compétences culturelles et éthiques des ergothérapeutes.

Talking About Professionalism Through the Lens of Professional Identity

Professionalism is one of the Accreditation Council for Graduate Medical Education's (ACGME) Core Competencies, but the breadth of its content often makes this a difficult topic, both in remedial counseling and when presenting the topic to medical trainees and practicing clinicians. Physician professionalism encompasses both clinical competence and the virtues that comprise the physician's social contract. This difficult subject may best be approached tangentially, through the lens of professional identity. Professional identity describes clinicians' affinity for, acculturation into, and identification with the practice of medicine. One method to highlight the benefits that individuals accrue by adopting professionalism's elements is to pose questions that optimize listeners' self-reflection about their lives and aspirations-in essence, their professional identity. Discussing professionalism this way often yields in-depth discussions of how trainees believe their professional identity was formed and will impact their long-term goals. Both in teaching and in counseling, educators can frame their discussions using professionalism and professional identity's overlapping and reinforcing elements to show listeners how to advance their personal and professional goals and avoid the short- and long-term consequences of unprofessional behavior. To engage the audience, educators and supervisors can emphasize how adhering to the elements of professionalism may determine their career opportunities, the professional respect they receive, and their career fulfillment and, ultimately, longevity. In this way, educators can better guide trainees and clinicians to understand their personal reasons for acting professionally, that is, doing the right thing, at the right time, in the right way, and for the right reason.

Defining professionalism for mental health services: a rapid systematic review

Background: Efforts have been made to define professionalism across the professions, yet little attention has been paid to the concept in mental health services, where patients' needs differ to that in other healthcare specialties. Aims: To derive a definition of professionalism for mental health services using the existing literature. Method: A rapid, systematic review was conducted to identify empirical and non-empirical records that described professionalism in a mental health service context from 2006 to 2017. Studies were synthesised narratively using thematic analysis. Results: Seventy records were included in the review. Professionalism was described on two levels; at a societal level, a dynamic social contract between professions and society, and; at an individual level, having intrapersonal, interpersonal, and working professionalism. Utilising emerging themes, an operationalised definition of professionalism, suitable for a mental health service context was derived. Conclusions: Within mental health services, emphasis is placed on the interpersonal aspects of practice such as communication skills, maintaining boundaries and humanity. Themes relating to the vulnerability of patients and the challenge of supporting autonomy and choice whilst maintaining safety and acting in a client's best interest are also evident. 'Practical wisdom' and a flexible approach to working are needed to manage these challenging situations.

Pilot evaluation of an objective structured assessment of technical skills tool for chest tube insertion

Background: Chest tube insertion is a standard intervention for management of various injuries of the thorax. Efficient clinical training of this and similar bed-side procedures is equally demanded and improvable. Here, we propose a nouveau means of assessment and feedback using an Objective Structured Assessment of Technical Skills (OSATS) tool. The modified OSATS for chest drain insertion is evaluated in a pilot trial focusing on chest drain insertion. Methods: Participants in the pilot trial were medical students (3^rd-6^th year of studies, n=9), junior residents (1^st-3^rd post-graduate year, n=12), senior residents (4^th-6^th post-graduate year, n=14), and attending surgeons (n=6) from Heidelberg University. Chest drain insertions on a cadaveric porcine model were rated by experts with the modified OSATS score. Participants' performances were videotaped and subsequently rated by two remote experts (video rating). Primary aim was to assess criterion validity of the OSATS to distinguish experience levels. Results: Kruskal-Wallis test showed significant differences between means of scores between four groups stratified by previous experience in chest tube insertion (level 0: 22.1±3.2 vs. level 1: 26.8±2.8 vs. level 2: 35.4±2.2 vs. level 3: 41.0±2.0; p=0.002; p_1,3=0.049, p_0,3=0.005). However, if groups were stratified by formal professional level, no statistically significant distinction could be made using OSATS. Hence, the OSATS tool showed criterion validity for differentiation between experience levels. Conclusion: In the pilot study, the modified OSATS for chest tube insertion was apt to standardize expert rating and could be used to measure skill and to depict different experience levels. The OSATS will help facilitate training and assessment of chest drain insertion and could therefore improve surgical training for trauma situations. According to our data, the OSATS might be integrated into modern curricula.

Developing Value-Orientations in Family Therapy Trainees: A Three-Year Investigation

Family therapy has advanced as an important therapeutic approach in Europe and, in Germany, future family therapists enter a three-year-training programme every year. Family therapist trainees (FTTs) have hardly been studied in terms of their value-orientations (VOs) and how they see the world. This study aims at researching the value-orientation developments in FTTs during the three-year training period and based on the Schwartz value model. A longitudinal study was carried out over a three-year period. The sample consisted of 65 FTTs. VOs were investigated using open questions in self-developed questionnaires. The findings show that FTTs focus mainly on VOs in the Schwartz value domain of "benevolence", followed by "self-direction" and "universalism". This shows that the well-being of others is in the centre of interest in FTTs. However, VOs which indicate a freedom to make decisions and be self-directed are also extremely important. The least-mentioned value domains include "power" and "stimulation", showing that FTTs are neither focused on status, wealth or richness, nor on excitement or a varied life. With regard to the Schwartz value dimensions, the dimension of "self-transcendence" was the most frequently mentioned, followed by "conservation", "openness to change" and "self-enhancement". Self-transcendence includes the value domains of benevolence and universalism and shows that the preservation and enhancement of welfare of other individuals are highly important, as well as VOs such as understanding, appreciation, tolerance and protection of human beings and the environment. So-called collectivist VOs seem to be more important to German FTTs than individualistic VOs: they focus on the needs of the social group and their VOs show that the systemic view is inherent in their social VOs. Findings further show that FTTs develop their professional identity while consciously strengthening their VOs. This study contradicts previous research which claims that FTs are, to a large extent, unconscious in respect of their VOs. The study shows that FTTs are aware of their VOs and this supports them in facilitating client-centred approaches and develop themselves as FT professionals. Recommendations for future research and practice are provided.

Reframing Professionalism: The Virtuous Professional

This article was migrated. The article was marked as recommended. In response to prevalent unprofessional behaviors during the 1990s, the medical school administration at Michigan State University's College of Human Medicine developed a student curriculum for professional development, called "The Virtuous Student Physician." However, as students adopted these professional aspirations and attributes, they noted that faculty members were not being held to the same standards. The medical school's senior associate dean for faculty affairs and development convened a task force to reframe professionalism for all faculty, residents, and students. Our first step was to survey our faculty regarding their awareness of the student professionalism curriculum and their own perceived professional weaknesses. This survey showed the following: most faculty members were aware of "The Virtuous Student Physician" curriculum, that faculty members identified social responsibility as the most difficult attribute to achieve, and that the most difficult behavior identified was working to resolve problem behaviors with colleagues. The task force then developed a new curriculum "The Virtuous Professional: A System of Professional Development for Students, Residents, and Faculty." The task force identified three core virtues (Courage, Humility, and Mercy) and reframed the professional attributes encompassed by these virtues to be aspirational for the entire learning community. The faculty of the College subsequently adopted the new principles and practices, including the use of routine, anonymous student evaluation of faculty professionalism. We are currently collecting data from student evaluations of their clinical faculty members. We plan to use this feedback to guide faculty development and recognize those who model exemplary professionalism as well as to address those who engage in unprofessional behavior.

Medical students' perceptions of professional misconduct: relationship with typology and year of programme

AIM

To examine the contribution of programme year and demographic factors to medical students' perceptions of evidence-based classification categories of professional misconduct.

METHODS

Students at an Irish medical school were administered a cross-sectional survey comprising 31 vignettes of professional misconduct, which mapped onto a 12-category classification system. Students scored each item using a 5-point Likert scale, where 1 represents the least severe form of misconduct and 5 the most severe.

RESULTS

Of the 1012 eligible respondents, 561 students completed the survey, providing a response rate of 55%. Items pertaining to disclosure of conflict of interest were ranked as the least severe examples of professional misconduct, and this perception was highest among finalyear students. While ratings of severity declined for items related to 'inappropriate conduct not in relation to patient' and 'inappropriate use of social media' between years 1 and 3, ratings for both categories increased again among clinical cycle (fourth and final year) students.

CONCLUSIONS

Increased clinical exposure during years 4 and 5 of the undergraduate programme was associated with better recognition of the importance of selected professional domains. Disclosure of conflict of interest is identified as an area of medical professionalism that requires greater emphasis for students who are at the point of transition from student to doctor.

A Mixed-Methods Approach to Humanistic Interprofessional Faculty Development

INTRODUCTION

This study evaluated the effectiveness of the Mentoring and Professionalism in Training (MAP-IT) program, a longitudinal, interprofessional faculty development curriculum designed to enhance clinicians' humanistic mentoring skills, specifically nurses and physicians.

METHODS

During 2014 to 2016, two consecutive cohorts of nurses and physicians completed the MAP-IT program. Participants included 169 high potential mentors (HPMs) and 61 facilitator leaders. Each 10-month program consisted of small group work, experiential learning, and critical reflection aimed at enhancing humanistic mentoring skills. Throughout the program, facilitator leaders served as mentors for the HPMs. Both quantitative and qualitative data were collected to measure changes in skill levels specific to humanistic teaching practices, as well as overall evaluation of the program's curriculum and logistics. Quantitative data were analyzed using the Wilcoxon signed-rank test, descriptive statistics, and Fisher exact test, as appropriate. Qualitative data assessing the overall impact and applicability of the program to the clinical setting were analyzed using content analysis methodology.

RESULTS

Across cohorts, HPMs demonstrated significant increases in perceptions of humanistic teaching skills. During objective structured teaching simulations, significant increases were also found in HPMs' self-reported mentoring skills and their skills as rated by a standardized RN/MD. Qualitative analyses revealed themes of the program to be skill development and application, mentorship, humanism, mindfulness, self-care, and acknowledgment of overlapping interprofessional roles.

DISCUSSION

Utilizing an interprofessional education approach, the MAP-IT program was determined to be a feasible strategy to positively impact the personal and professional development of nurses and physicians.

Differences between medical student and faculty perceptions of the competencies needed for the first year of residency

BACKGROUND

Different guidelines and frameworks like the CanMEDs model or entrustable professional activities (EPAs) describe competencies required for successful and professional work of residents. Not all competencies are of equal importance for graduates when they start their residency. The aim of this study was to evaluate the relevance of different competencies for a first year resident from the perspective of physicians and medical students.

METHODS

In an online study, 178 of 475 surgeons and internists including residents and attendings and 102 of 728 first and last year undergraduate medical students from the University Medical Center Hamburg-Eppendorf ranked 25 competencies according to their relevance for entrustment decisions in first year residents. The rankings of the competencies by residents and attendings and by first year and last year medical student were compared. Additionally, the rankings were also compared to the literature.

RESULTS

Physicians and medical students rated 'Responsibility' as the most important competency for first year residents. Physicians ranked 'Teamwork and collegiality' and 'Structure, work planning and priorities' within the top 10 competencies significantly higher than medical students. The competency ranks between attendings and residents only showed one significant difference between attendings and residents, where 'Coping with mistakes', was ranked significantly higher by residents. Medical students ranked 'Active listening to patients', 'Advising patients' and 'Handling emotions of patients and their relatives' significantly higher than physicians. Final year students ranked 'Structure, work planning and priorities', 'Coping with mistakes', and 'Verbal communication with colleagues and supervisors' significantly higher than first year students.

CONCLUSIONS

Even though physicians and medical students agree that 'Responsibility' is the most important competency for entrustment decisions in the first year of residency, medical students rate competencies regarding patient communication very highly while physicians rate competencies required for patient managements significantly higher for entrustment decision. Undergraduate medical curricula seem to prepare students well with respect to patient-centeredness but need to be developed more specifically to prepare students equally well for patient management competencies which are required in the first year of residency for entrustment decisions from the attendings perspective.

Imbuing medical professionalism in relation to safety: a study protocol for a mixed-methods intervention focused on trialling an embedded learning approach that centres on the use of a custom designed board game

INTRODUCTION

Healthcare organisations have a responsibility for ensuring that the governance of workplace settings creates a culture that supports good professional practice. Encouraging such a culture needs to start from an understanding of the factors that make it difficult for health professionals to raise issues of concern in relation to patient safety. The focus of this study is to determine whether a customised education intervention, developed as part of the study, with interns and senior house officers (SHOs) can imbue a culture of medical professionalism in relation to patient safety and support junior doctors to raise issues of concern, while shaping a culture of responsiveness and learning.

METHODS AND ANALYSIS

We will use quantitative and qualitative methods to collect data. The sample size will be approximately 200 interns and SHOs across the two hospital sites. Two surveys will be included with one measuring leadership inclusiveness and psychological safety and a second capturing information on safety concerns that participants may have witnessed in their places of work. The PlayDecide embedded learning intervention will be developed with key stakeholders. This will be trialled in the middle stage of data collection for both interns and SHOs. A detailed content analysis will be conducted on the surveys to assess any changes in reporting following the PlayDecide intervention. This will be compared with the incident reporting levels and the results of the preintervention and postintervention leadership inclusiveness and psychological safety survey. Statistical analysis will be conducted using SPSS. Differences will be considered statistically significant at p<0.05. Semistructured interviews using a critical incident technique will be used for the ongoing analysis and evaluation of the project. These will be transcribed, de-identified and coded into themes.

ETHICS AND DISSEMINATION

The study has been granted ethics approval from University College Dublin (Ref. LS-15-19-Ward-McAuliffe: Imbuing Medical Professionalism in Relation to Safety). The study results will be disseminated through peer-reviewed publications.

A qualitative thematic content analysis of medical students' essays on professionalism

BACKGROUND

Physicians in both Western and Eastern countries are being confronted by changes in health care delivery systems and medical professionalism values. The traditional concept of "In-Sul" (benevolent art) and the modern history of South Korea have led to cultural differences between South Korea and other countries in conceptualizing medical professionalism; thus, we studied medical students' perceptions of professionalism as described in essays written on this topic.

METHODS

In 2014, we asked 109 first-year medical students who were enrolled in a compulsory ethics course to anonymously write a description of an instance of medical professionalism that they had witnessed, as well as reflecting on their own professional context. We then processed 105 valid essays using thematic content analysis with computer-assisted qualitative data analysis software.

RESULTS

Thematic analysis of the students' essays revealed two core aspects of professionalism in South Korea, one focused on respect for patients and the other on physicians' accountability. The most common theme regarding physician-patient relationships was trust. By contrast, distributive justice was thought to be a non-essential aspect of professionalism.

CONCLUSIONS

In Western countries, physicians tend to promote justice in the health care system, including fair distribution of medical resources; however, we found that medical students in South Korea were more inclined to emphasize doctors' relationships with patients. Medical educators should develop curricular interventions regarding medical professionalism to meet the legitimate needs of patients in their own culture. Because professionalism is a dynamic construct of culture, medical educators should reaffirm cultural context-specific definitions of professionalism for development of associated curricula.

Causes and characteristics of medical student referrals to a professional behaviour board

OBJECTIVES

To describe the nature of unprofessional behaviour displayed by medical students, as well as the characteristics of students referred to the professional behaviour board.

METHODS

A descriptive mixed methods approach was taken, in which qualitative data on unprofessional behaviour, as well as quantitative data on the demographics of referred students were collected during the study period between June 1, 2009 and January 1, 2014. In order to compare the referred students with the total student population, data on gender, nationality and phase in the curriculum of the total student population, collected from the student administration desk, were also used.

RESULTS

In the study period, a total of 107 referrals were reported, concerning 93 different students (3% of the total student population). Sixty-five of the 107 referrals (61%) concerned male students. Thirty referrals (28%) concerned non-Dutch students. Most referrals (71%) occurred during clinical rotations. The referrals were equally distributed over three professional behaviour domains: dealing with oneself, dealing with others, and dealing with tasks/work. 'Withdrawn behaviour' was reported 17 times, 'insufficient Dutch language proficiency' 14 times, 'impertinent emails' 9 times and 'placing privacy-sensitive photos on the internet' 3 times.

CONCLUSIONS

Although only a minority of students are referred to a professional behaviour board, this study shows that student characteristics such as gender and nationality may correlate to a higher incidence of unprofessional behaviour. Further explanatory and exploratory research is needed to unravel this relationship, and to study the influence of curriculum reforms on these relationships, respectively.