Integrating professionalism into the curriculum: AMEE Guide No. 61

Assessment of Professionalism among Postgraduate Medical Students: A Cross-Sectional Study from Patna, Bihar

BACKGROUND

Professionalism is a core quality which has to be developed and imbibed by medical students. However, training in professionalism was not a part of the medical curriculum until recently when the Competency-Based Medical Education system was introduced for undergraduate medical students in India, by the National Medical Commission. However, there has been no formal training on professionalism, in the curriculum of postgraduate (PG) medical students in India. Therefore, in this study, we have done a quantitative assessment of the attitude towards professionalism among PG medical students.

METHODOLOGY

A cross-sectional study was conducted among 200 PG medical students of an autonomous institute in Patna, Bihar over a period of six months using the Learners' Attitudes on Medical Professionalism Scale (LAMPS) questionnaire. Data entry was done on Microsft Excel 2015 (Microsoft Corporation, Redmond, Washington, United States) and data analysis was done using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States).

RESULTS

Out of 200 study subjects, 55% (n=110) were PG students from clinical departments and 45% (n=90) were from pre-clinical and para-clinical departments; 25.5% (n=51) of them were from first year, 57% (n=114) of them were from second year, and 17.5% (n=35) were from third year PG training. The overall mean score for the LAMPS scale across all domains was found to be 2.78±0.178 (mean±S.D). Clinical PG students (2.99 ± 0.217) received significantly higher scores than pre/paraclinical PG students (2.68 ± 0.176) (T-test value = 10.9262, p < 0.0001).

CONCLUSION

This study highlights the disparity in professionalism scores between clinical and pre/para-clinical students, suggesting a tailored approach might be beneficial. In order to improve the attitude towards professionalism, structured courses/workshops should be inculcated into the PG training curriculum. Continuous evaluation of professionalism throughout medical training can lead to better preparedness for future professional roles.

A modified Delphi approach to nurturing professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

METHODS

A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

RESULTS

A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Reflective practice in medicine: The hidden curriculum challenge

BACKGROUND

Despite the known benefits of reflection in various health care professions, it is still not a thriving practice in medical education. The literature suggests that this may be due to tensions between epistemological tenets of reflection and biomedicine. Further research is needed into experiences of doctors as they implement reflection in medical education settings. We set out to explore how these experiences were influenced by hidden curricula to provide insights into personal and contextual features of medical settings influencing engagement in reflection.

METHODS

Using an interpretative phenomenological analysis (IPA) approach, four semi-structured qualitative interviews were conducted virtually. Participants were doctors who graduated from a postgraduate diploma in clinical education with core reflective practice components. Interviews were recorded, transcribed, coded and analysed using IPA. Opportunities to review and amend transcriptions were provided.

FINDINGS

Three superordinate themes were identified including epistemological divergence, fear of showing vulnerability and reflection volte-face. Challenges in engaging in practices epistemologically different to predominant discourses in medicine were compounded by fears of vulnerability and a common antipathy towards reflection. All developed more accommodating perspectives towards reflection with shared experiences of a programme incorporating reflective practice.

CONCLUSION

The hidden curriculum can have positive and negative impacts on doctors' engagement in reflection. In facilitating reflective practice for this group, we recommend assisting with awareness of ways of thinking and being in medicine, offering reassurance that reflection may initially feel like running contrary to predominant discourses and finally, role modelling openness to vulnerability to better integrate and promote meaningful engagement in reflection.

Professionalism-training in undergraduate medical education in a multi-cultural, multi-ethnic setting in the Gulf Region: an exploration of reflective essays

BACKGROUND

Despite the established need to prioritize professionalism-training in developing future physicians, very few medical programs in the Gulf Region embed in their curricula discrete contextualized courses aimed at developing the corresponding competencies, while fostering self-directed learning. This study aims at exploring the perception of undergraduate medical students in a multi-cultural, multi-ethnic setting regarding their understanding of, and personal experience with professionalism through their engagement with the content of an innovative curriculum-based professionalism course, offered at a Medical School in Dubai, United Arab Emirates.

METHODS

The study used a qualitative phenomenological research design. Out of 33 students, 29 students had submitted reflective essays. The content of these essays was inductively analyzed following a six-step framework for conducting thematic analysis. The framework's steps include familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.

FINDINGS

The inductive qualitative analysis generated the Professionalism Learning Journey model. This conceptual model includes four interconnected themes: Awareness, Acknowledgement, Realization, and Application. The generated model depicts the trajectory that the learners appear to experience while they are engaging with the content of the course.

CONCLUSION

Integrating a professionalism-training course into an undergraduate medical curriculum is likely to be positively appraised by the learners. It raises their awareness, enables them to value the subject matter and the sophistication of its application, and empowers them to put into practice the taught principles, on an individual basis and collectively. This is especially true when the course is entrenched in constructivism experiential learning theory and designed to foster self-directed learning. The introduced conceptual model, in conjunction with the innovative professionalism-training course curriculum, can serve as a template for other competencies and other schools.

Divergence and Convergence of the Public Health Leadership Competency Framework Against Others in Undergraduate Medical Education: A Scoping Review

Objective: The following scoping review is aimed at identifying leadership competency frameworks in Undergraduate Medical Education (UME) by analyzing the thematic scopes, target audiences, and methods involved. A further objective is to compare the frameworks against a standard framework. Methods: The authors extracted the thematic scope and methods of each framework based on the original author's formulations in each selected paper. The target audience was divided into three sections: UME, medical education, and beyond medical education. The frameworks were converged and diverged against the public health leadership competency framework. Results: Thirty-three frameworks covering thematic scopes such as refugees and migrants were identified. The most common methods to develop leadership frameworks were reviews and interviews. The courses targeted multiple disciplines including medicine and nurses. The identified competency frameworks have not converged among important domains of leadership such as systems thinking, political leadership, leading change, and emotional intelligence. Conclusion: There is a variety of frameworks that support leadership in UME. Nevertheless, they are not consistent in vital domains to face worldwide health challenges. Interdisciplinary and transdisciplinary leadership competency frameworks which address health challenges should be used in UME.

A Mixed-Methods Systematic Review of Group Reflective Practice in Medical Students

BACKGROUND

Used primarily as a pedagogical evaluation tool for didactic teaching and skill development, reflective practice (RP) for its own merits is poorly understood. This study aimed to systematically review the literature regarding the role of group RP in fostering empathy, wellbeing, and professionalism in medical students.

METHODS

Electronic searches of empirical studies published between 1 January 2010 and 22 March 2022 from Medline, Embase, and PsychINFO databases were conducted. Empirical studies of any design (qualitative or quantitative) which included RP (1) involving medical students; (2) with a focus on fostering empathy, or professionalism, or personal wellbeing; and (3) provided in a group setting were included. Duplicates, non-English articles, grey literature and articles using RP to examine pedagogy and specific technical skills were excluded. Both authors screened articles independently to derive a final list of included studies, with any discrepancies resolved by discussion, until consensus reached. Articles were rated for methodological quality using the Attree and Milton checklist for qualitative studies; the Oxford Centre for Evidence-Based Medicine criteria, and the Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative studies.

RESULTS

Of 314 articles identified, 18 were included: 9 qualitative; 4 quantitative and 5 mixed methodology. Settings included United States (6), United Kingdom (3), Australia (3), France (2), Taiwan (2), Germany (1), and Ireland (1). Themes were (i) professionalism: bridging theoretical paradigms and practice; (ii) halting empathy decline; (iii) wellbeing: shared experience. Additional themes regarding the "successful" delivery of RP groups in facilitating these outcomes also emerged.

CONCLUSIONS

This first systematic review of group RP in medical students shows that RP may bring theory to life in clinical dilemmas, while fostering collegiality and mitigating against isolation amongst students, despite the absence of studies directly examining wellbeing. These findings support the value of RP integration focusing on emotive and humanitarian processes into contemporary medical education for medical students.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022322496.

Factors influencing professionalism during dental training at the University of Chile: perception of students and patients

BACKGROUND

The University should be considered a favourable space and agent for the training and transmission of values and attitudes related to professionalism, such as responsibility, teamwork and ethical commitment. In addition, dentistry is a profession with a deep social sense that seeks to solve the oral health problems of the population to improve the quality of life. In this context, our aim was to explore the perception of students and patients about the contribution of the curriculum to the development of professionalism and to identify the factors that strengthen and weaken this perception.

METHODS

A qualitative approach was carried out through focus groups and semi-structured interviews with students from the 4th, 5th and 6th year of training and patients treated at the Dental Clinic of our Faculty.

RESULTS

In the opinion of patients and students, the factors that debilitate the training in professionalism are associated with weakened professional values/behaviours in the training, the lack of teacher training of the professors and factors of educational environment. On the contrary, factors strengthening the professionalism are mainly related to hallmark values/ professional behaviours trained in the institution and to the good evaluation by patients. The respondents also perceive the implementation of a new curriculum as a positive factor for the training in professionalism.

CONCLUSION

The patients and students interviewed believe that the main strength for the training in professionalism in the institution is the development of adaptability for the future professionals to any social context, especially to a vulnerable one, the ability to solve the problems they face and the responsibility towards the patients and their treatment.

Characteristics and patients’ portrayals of Norwegian social media memes. A mixed methods analysis

Background

Despite reports on troublesome contents created and shared online by healthcare professionals, a systematic inquiry of this potential problem has been missing. Our objective was to characterize the content of healthcare-associated social media memes in terms of common themes and how patients were portrayed.

Materials and methods

This study applied a mixed methods approach to characterize the contents of Instagram memes from popular medicine- or nursing-associated accounts in Norway. In total, 2,269 posts from 18 Instagram accounts were included and coded for thematic contents. In addition, we conducted a comprehensive thematic analysis of 30 selected posts directly related to patients.

Results

A fifth of all posts (21%) were related to patients, including 139 posts (6%) related to vulnerable patients. Work was, however, the most common theme overall (59%). Nursing-associated accounts posted more patient-related contents than medicine-associated accounts (p &lt; 0.01), but the difference may be partly explained by the former focusing on work life rather than student life. Patient-related posts often thematized (1) trust and breach of trust, (2) difficulties and discomfort at work, and (3) comical aspects of everyday life as a healthcare professional.

Discussion

We found that a considerable number of Instagram posts from healthcare-associated accounts included patients and that these posts were diverse in terms of contents and offensiveness. Awareness that professional values also apply online is important for both healthcare students and healthcare providers. Social media memes can act as an educational resource to facilitate discussions about (e-)professionalism, the challenges and coping of everyday life, and ethical conflicts arising in healthcare settings.

Mindset and Reflection—How to Sustainably Improve Intra- and Interpersonal Competences in Medical Education

Intra- and interpersonal competences (IICs) are essential for medical expertise. However, the effects of current medical curricula seem to not be sustainable enough, even though poorly trained IICs have negative effects on medical practice. A defensive attitude towards openly addressing personal–professional challenges seems to hinder a sustainable implementation of IICs training. Therefore, this study asks about the changeability of IICs and target factors of their implementation in medical education. The aim was to detect factors for the sustainable implementation of IICs in medical education from medical and non-medical perspectives. For this purpose, a total of 21 experts were interviewed. The interview material was analysed according to grounded theory principles to generate core categories to answer the research questions. As a first result, analysis revealed that IICs are changeable and developable, not in all, but in many students. It also showed four central prerequisites for successful implementation: the longitudinal integration of reflection and feedback in medical education and practice; a clear framework and individual path of education; the students’ mindset to develop themselves on a personal level; as well as the superiors’ mindset to openly deal with personal challenges in low hierarchies. Contrasting Carol Dweck’s mindset concept with our findings supports our theory that the development of a mindset which allows an open approach to personal deficits and challenges seems to be of central importance for both students and teachers. Two key factors in this process might be teaching about the impact of mindsets on learning and the willingness of superiors to openly address their personal challenges. To improve IICs in medical professionals, it seems helpful to pay more attention to the development of mindsets. Educating teachers and superiors about targeting factors could be a feasible direction for sustainable implementation.

"It really puts me in a bind", professionalism dilemmas reported by Chinese residents

Residents play a pivotal role in the healthcare system. However, few tools have systematically revealed the dilemmas and challenges faced by residents. This study aimed to develop a checklist for professionalism dilemmas based on a behavior-based professionalism framework and to examine the range and proportion of professionalism dilemmas heard of, witnessed, or experienced by Chinese residents. Mixed methods were used, comprising qualitative (document analysis and focus group interviews) and quantitative (a small-scale questionnaire survey) data. Document analysis summarized professionalism dilemma items from previous publications. For focus group interviews, we used narrative inquiry to explore and make sense of residents' experiences and perceptions of professionalism dilemmas. A small-scale questionnaire survey was conducted during each focus group to investigate the proportion of professionalism dilemma items that residents reported to have heard of, witnessed, or experienced. Through document analysis and focus group interviews, we developed a checklist of professionalism dilemmas based on a behavior-based professionalism framework. The checklist included 58 items over four domains, with 10 sub-domains (compassion, respect, communication, collaboration, integrity, duty, pursuit of excellence, fair stewardship of health care resources, patient confidentiality, and informed consent). We also sought a preliminarily subjective impression by exploring the proportion of residents who have heard of, witnessed, and experienced each of the professionalism dilemma items and residents' perspectives when faced with professionalism dilemmas. Residents inevitably encounter or experience a diverse range of professionalism dilemmas. This checklist of professionalism dilemmas that was developed could prove to be a significant reference for targeted professionalism education, both for the resident as well as for faculty. It can also act as a helpful tool for improving hospital management guidelines and patient education.

What we think about professional and unprofessional behaviors: differences between the perception of clinical faculty members and medical students

INTRODUCTION

Differences in the viewpoints of clinical faculty members and medical students about prioritizing professional norms accepted by the professional community and lack of alignment of these views can lead to distortion of understanding, problems in learning and assessment of professionalism, and failure in students' professional identity formation. This study aimed to identify the differences in viewpoints of clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors among undergraduate medical students.

METHODS

A multi-stage qualitative study was conducted at Tehran University of Medical Sciences during 2020-2021. At first, a systematic search was conducted to identify professional and unprofessional behaviors using the directional content analysis method. A panel of experts was formed to check the codes obtained from reviewing the literature and to evaluate its compliance with the context. Then, the modified nominal group technique sessions were held with clinical faculty members and medical students to strengthen the codes extracted from the studies and systematically integrate their views to achieve a comprehensive list of professional and unprofessional behaviors in accordance with the context. Finally, a consensus was made among them about prioritizing the importance and prevalence of these behaviors in undergraduate medical students.

RESULTS

A total of 490 codes of professional behaviors and 595 unprofessional behavior codes were identified in the literature review. In the following sessions of the modified nominal group, 13 clinical faculty members listed 105 codes of professional and unprofessional behaviors, and 51 medical students also listed 313 codes. The results of the modified nominal group technique showed that the faculty members reported the importance of unprofessional behaviors higher than professional ones. At the same time, students rated the importance of professional behaviors higher than unprofessional ones. Both faculty members and students rate the prevalence of professional behaviors as high and the prevalence of unprofessional behaviors as low.

CONCLUSION

The results showed a difference of views between clinical faculty members and medical students about prioritizing professional and unprofessional behaviors. It is essential to align their viewpoints to understand, learn and value professionalism to develop a professional identity.

Educational content of professional ethics in postgraduate dental education

PURPOSE

Inclusion of proper educational content with respect to professional ethics in dental curricula is an important step to achieve objectives of ethics education especially in postgraduate programs when the time and opportunities for explicit instruction of ethics are limited. This study aimed to find and discuss the topics of ethics and professionalism for dental postgraduate programs.

METHODS

A modified Delphi survey of experts' opinions with three rounds was conducted to establish a consensus on the need to teach professional ethics topics. The topics were identified through a literature review and according to the opinion of the experts. Items scored as highly important by over 80% of the participants in each round of the survey were considered educational needs.

RESULTS

A total of 154 ethical issues were identified and classified into 29 topical categories to design the initial questionnaire. A consensus was developed on 24 ethics and professionalism topics for inclusion in the professional ethics curriculum for all dental postgraduate programs.

CONCLUSIONS

Based on the results of this study, the same educational content in professional ethics is needed for all dental residency programs in all specialties. Most of the topics on which experts reached a consensus to be included in the ethics educational content were related to ethical and professional standards of conduct.

Does professionalism change with different sociodemographic variables? A survey of Arab medical residents

BACKGROUND

Medical professionalism reflects the commitment of physicians to their patients, society, themselves, and the profession. The study examined residents' attitudes towards professionalism and how these attitudes vary among the different demographic groups, namely gender, specialty, and year of residency.

METHODS

A proportionate random sampling strategy was used to select the study sample. Medical residents from six specialties at a large tertiary care teaching facility were invited to participate in an online survey. The survey used the modified Learners Attitude of Medical Professionalism Scale (LAMPS), which consists of five domains: respect, excellence, altruism, duty/accountability, and integrity. Chi-square, Student t-test, one-way ANOVA, factorial ANOVA, and post hoc analysis were used to examine the attitudinal differences towards professionalism among the different demographic factors.

RESULTS

The overall response rate was 82.7%. Overall, the residents' self-reported attitudes towards professionalism was positive. The highest score was for the "respect" domain (4.61), and the lowest was for "altruism" (3.67). No significant association was found between the mean scores and the three studied variables, namely, gender, specialty (surgical/nonsurgical), and level (senior/junior).

CONCLUSIONS

No significant differences were observed in the overall attitude towards professionalism among the residents regarding their year of residency, gender, and specialty. The low altruism score and absence of improvement of the total score regarding the residents' increasing experience in the profession are concerns that need remedial action. Therefore, we suggest that future research look for possible explanations by using multi-institutional surveys that explore not only the residents' attitudes, but also the trainers' attitudes and practice, work situations, the hidden curriculum, and culture. Key messagesAttitudes towards professionalism among different demographic groups of residents do not show similar variations as has been reported in the literature, albeit in different sociocultural contexts.The low altruism score and absence of improvement of the total score as the residents gained more experience in the profession are concerns that need remedial action.A longitudinal study involving more than one institution for both residents and their faculty members to compare faculty scores with those of residents, while controlling for specialty and gender, may help elucidate the factors affecting attitudes towards professionalism and suggest possible means of addressing unfavourable attitudes.

Use of simulated patients for formative assessment of moral competence in medical students

BACKGROUND

During the course of their education, medical students must attain moral competence. The current study aims at designing a formative structured examination that would create the opportunity for learners to practice and interact with simulated patients under expert supervision.

MATERIALS AND METHODS

This article reports an experience in developing and implementation of a formative assessment of moral competence and the point of view of medical students. In this study, the formative structured examination of medical ethics for 80 medical students in 2 rounds with eight stations was designed. In each station, a scenario was proposed, and the opportunity was provided to the learners to interact with a simulated patient under the supervision of a medical ethics expert. Then, the learners would receive structured feedback in accordance with their performance. All learners expressed their experience in reflective writing, and their opinions were put under content analysis.

RESULTS

The content analysis of this reflective writing revealed three main categories, namely "Deeper understanding of ethical subjects," "Collaborative thinking and synergy with peers," and "Effective feedback of supervisors."

CONCLUSION

Within the framework of a formative structured examination of medical ethics, a safe space was created for interacting with simulated patients and practicing ethical reasoning, as well as dimensions of moral competence.

The assessment of personal and professional identity development in an undergraduate medical curriculum: A scoping review protocol

Background: Over recent years there has been significant interest in the field of medical education in understanding how medical students develop their personal and professional identity as they transition through medical school and into their early career. Despite the growing amount of research that focuses on the best methods of incorporating this area into medical school curricula, there has been less focus on how to assess this construct and how it might be associated with student progression. Therefore, a scoping review is being undertaken to identify the various methods or tools currently being implemented to assess the development of personal and professional identity, including the concepts of professionalism, leadership and resilience, in medical education and outline an optimal assessment framework. Methods: The proposed scoping review of the literature will be conducted under the guidance of the methodology of the Joanna Briggs Institute for scoping reviews across multiple electronic databases. Electronic database, reference list, and citation searching from the year 2000 will be undertaken. Peer reviewed publications involving assessment methods for personal and/or professional identity formation, professionalism, leadership, and resilience being utilised with direct-entry or graduate-entry medical students will be selected. The search strategy will remain dynamic and may be further delineated as necessary during the review process. All studies that meet this study’s inclusion criteria will undergo thematic analysis. The overall findings of this analysis will be presented in a narrative format. Conclusion: In this scoping review protocol, the current methods and tools for assessment of personal and/or professional identity formation, professionalism, leadership, and resilience will be identified and synthesised into a proposed assessment framework. The hope is that this framework will then serve as an aid to support the assessment of this multi-dimensional, complex construct.

Translating and validating a Japanese version of the instrument for patient assessment of medical professionalism (J-IPAMP): a cross-sectional survey

BACKGROUND

Although there are many tools to assess medical professionalism, they rarely address patients' perspectives. The instrument for patient assessment of medical professionalism (IPAMP) comprises 11 items and has been established and validated as a valuable tool for assessing trainees' professionalism from the patient's perspective. However, there is no instrument to assess professionalism from the patient's perspective in Japan. The purpose of the present study was to develop a Japanese version of the IPAMP (J-IPAMP) and test its validity and reliability.

METHODS

We conducted a cross-sectional survey to examine the reliability and validity of the J-IPAMP in two hospitals (one each in an urban and rural area) in Japan. Receptionists or surveyors distributed the anonymous questionnaire to 276 inpatients; all participants were aged above 20 years and assigned to medical trainees. We evaluated its structural and criterion-related validity, as well as internal consistency reliability.

RESULTS

Data of 235 (85.1%) patients were analyzed. Using the split-half validation technique, we performed an exploratory factor analysis (EFA) along with a confirmatory factor analysis (CFA). The EFA showed a one-factor solution. Then, to compare the model fitness between two models (the two-factor model from the original English version vs. unidimensional model suggested by the EFA), the CFA was performed. The CFA showed that almost all of the fit indices met their respective criteria and were approximately the same for the two models. Thus, we adopted a single-factor model. The Pearson correlation coefficients between the total J-IPAMP scores and the global ratings were 0.738, indicating adequate criterion-related validity. The Cronbach's alpha of the 11 items of the instrument was 0.96 (95% confidence interval: 0.96-0.97) and the omega value was 0.96, demonstrating acceptable internal consistency reliability.

CONCLUSIONS

We developed the Japanese version of the IPAMP. Its validity and reliability were verified through analysis. This instrument can be utilized for professionalism education in the postgraduate training setting.

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.

Exploring Professionalism among Final Year Dental Students and New Graduates: Translating Knowledge to Practice

OBJECTIVES

 The aim of this study was to evaluate senior students' and dental graduates' perception of professionalism as defined by international regulatory bodies and to assess students' ability to apply such knowledge in clinical-based scenarios.

MATERIALS AND METHODS

 Knowledge of professional competencies was conducted using a survey based on domains of professionalism for a newly qualified general dental practitioner as defined by international regulatory bodies. This survey consists of 32 items addressing participants' perception of three domains of professionalism. Application of the perceived professional competencies was tested by asking participants to answer questions following the observation of a clinical-based scenario video where participants needed to identify issues related to professional, ethical, and communication skills, which were embedded in the scenarios.

STATISTICAL ANALYSIS

 Differences were analyzed using ANOVA and t-tests (p<0.05).

RESULTS

 Data from 146 participants showed no significant differences in the survey scores between the participants' professional levels, place of practice, age groups, and genders. Analyses of correlation between the different domains of professionalism showed significant relationships between pair-wise comparisons of the total domain scores. Paired t-tests revealed that the mean score percentage for each of the three domains of professionalism was significantly higher than the responses reported in the relevant clinical-based scenario questions.

CONCLUSIONS

 This indicates that all domains of professionalism contributed in a similar way to their overall assessment. Furthermore, our findings show that dental practitioners may not be able to apply their knowledge of professionalism in real-life scenarios. This suggests that teaching professionalism at the early stages of the dental curriculum should incorporate innovative approaches to mimic real-life scenarios.

Pre-Clinical Medical Students' Use of Motivational and Cognitive Study Strategies During Anatomy Learning: A Three-Year Cross-Sectional Survey

Medical students' motivation and study strategies are crucial in determining academic performance. This study aimed to assess the motivation and learning strategies of medical students as well as their association with performance in anatomy examinations. The Motivated Strategies for Learning Questionnaire, two focus group discussions, and students' current anatomy cumulative grade point average (cGPA) were used. Generally, the medical students strongly felt that anatomy is fundamental to the practice of medicine and surgery. This result was consistent with high task value scores of 5.99 ± 1.25. They were also driven by extrinsic goal orientation (5.59 ± 1.42) and intrinsic goal orientation (5.08 ± 1.26). Most medical students typically relied on elaboration (5.35 ± 1.25) ahead of other cognitive strategies namely rehearsal (5.30 ± 1.11), organization (5.15 ± 1.34), and lowest-rated critical thinking (4.77 ± 1.19). The students also relied on resource management strategies, effort regulation (5.15 ± 1.20) and time and study environment regulation (5.03 ± 1.03) more than the moderately scored peer learning (4.95 ± 1.50) and help-seeking (4.95 ± 1.09). In the focus group discussions, students reported that they often narrate or explain to each other what they would have read and understood from anatomy lectures, tutorials, and textbooks. They also bemoaned the lack of institutional support for stress burdens. The motivation and learning strategies subscales were not correlated with anatomy cGPA. Males were driven by extrinsic goals and experienced significantly higher levels of test anxiety than females (P < 0.05). Knowing the motivation and learning strategies students employ early in the medical curriculum can be leveraged to promote self-directed learning and academic achievement.

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.

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 Meaningful and Actionable Professionalism Assessment: Validity Evidence for the Professionalism Mini-Evaluation Exercise (P-MEX) Across 8 Years

PURPOSE

With the growing importance of professionalism in medical education, it is imperative to develop professionalism assessments that demonstrate robust validity evidence. The Professionalism Mini-Evaluation Exercise (P-MEX) is an assessment that has demonstrated validity evidence in the authentic clinical setting. Identifying the factorial structure of professionalism assessments determines professionalism constructs that can be used to provide diagnostic and actionable feedback. This study examines validity evidence for the P-MEX, a focused and standardized assessment of professionalism, in a simulated patient setting.

METHOD

The P-MEX was administered to 275 pediatric residency applicants as part of a 3-station standardized patient encounter, pooling data over an 8-year period (2012 to 2019 residency admission years). Reliability and construct validity for the P-MEX were evaluated using Cronbach's alpha, exploratory factor analysis (EFA), and confirmatory factor analysis (CFA).

RESULTS

Cronbach's alpha for the P-MEX was 0.91. The EFA yielded 4 factors: doctor-patient relationship skills, interprofessional skills, professional demeanor, and reflective skills. The CFA demonstrated good model fit with a root-mean-square error of approximation of .058 and a comparative fit index of .92, confirming the reproducibility of the 4-factor structure of professionalism.

CONCLUSIONS

The P-MEX demonstrates construct validity as an assessment of professionalism, with 4 underlying subdomains in doctor-patient relationship skills, interprofessional skills, professional demeanor, and reflective skills. These results yield new confidence in providing diagnostic and actionable subscores within the P-MEX assessment. Educators may wish to integrate the P-MEX assessment into their professionalism curricula.

Medical professionalism research characteristics and hotspots: a 10-year bibliometric analysis of publications from 2010 to 2019

An abundance of publications on medical professionalism have been published in recent years. Our study aimed to analyze the external characteristics of publications on professionalism using bibliometrics, to describe its current developments and trends, and to explore professionalism research hotspots using co-word analysis. We retrieved literature on professionalism published from 2010 to 2019 from the Web of Science database. Histcite and CiteSpace were used to analyze external characteristics of publications, including publication trends and distributions of publications by country/region, institution, author, and journal. Co-word analysis was conducted to analyze research hotspots, using the Bibliographic Item Co-Occurrence Matrix Builder and Graphical Clustering Toolkit. We constructed a strategic diagram to show the state of each research hotspot and the relationship between the various hotspots in this field. Results showed publications on professionalism increased in number year by year as a whole. The USA, including its institutions and authors, maintained the top position worldwide in terms of numbers of publications and citations. Among scholarly journals, Academic Medicine has published more articles and has had higher citations per paper than any other journal. Six research hotspots on professionalism were identified, visualized, and expounded. Of these, the theme of "measurement and evaluation of clinical competence" received the most attention in the field of professionalism. The reporting of quantifiable knowledge on the characteristics and research hotspots of publications could help inform gaps in the field of medical professionalism and provide evidence and guidance for future work for researchers, physicians, and educators.

The Presence of Ghost Publications Among Canadian Plastic Surgery Residency Applicants: How Honest Are Canadians?

Background:

Physicians with history of unprofessional behaviour during their medical training are shown to be 3 times more likely to have board disciplinary action later in their career. One realm in which unprofessional behaviour takes place is the phenomenon of unverifiable publications or “ghost publications.” To that end, this study aims to assess the rate of ghost publications among a recent cohort of Canadian Plastic Surgery residency applicants to determine if this phenomenon is geographic in nature.

Methods:

The current study was a retrospective, cross-sectional observational study; a review of all residency applications submitted to a single Canadian Plastic Surgery residency program from 2015 to 2018 was performed and all their listed publications were verified for accuracy. The review was conducted by a third party librarian and a research coordinator blinded to the authors identifying information. “Ghost publication” was defined as any publication listed as “published,” “accepted,” or “in-press” that did not exist in the literature.

Results:

A total of 196 applications of 186 applicants were submitted over the span of 4 years. A total of 362 publications listed as peer-reviewed articles, belonging to 114 applications were extracted and reviewed. Among the 362 publications listed as peer-reviewed articles, 2 could not be found in the literature (0.55%). Additionally, 42 citations were found with 48 minor differences than what was cited.

Conclusions:

The rate of ghost publications among recent applicants to a Plastic Surgery residency program is low (less than 1%). Future studies should investigate methods to further improve and instill the value of professionalism in our future plastic surgery trainees.

Teaching Professionalism to Medical Students Using Dissection-Based Anatomy Education: a Practical Guide

Professionalism is a core competency for all healthcare professionals and is a subject of great interest within the academic community due to its vital importance in delivering the highest quality patient care. Despite this, professionalism remains difficult to define, teach and assess. The potential use of anatomy education in teaching professionalism has been increasingly highlighted within the literature, but still remains an underutilised tool in medical education. Therefore, this practical guide offers evidence-based practical points for successfully incorporating professionalism within a dissection-based anatomy course delivered to undergraduate medical students.

Communication training is inadequate: the role of deception, non-verbal communication, and cultural proficiency

In this commentary, we argue that the limited experiential exposure of medical students to different cultures makes the instruction devoted to communication skills inadequate. The relationship of these dynamics to honesty in clinical encounters is explored. Absent significant experiential exposure to differing group cultures to counter the natural tendency to favor one's own, discrimination prevails. Knowledge or awareness of cultural differences does not necessarily equate to communication proficiency. Critically, interactions based on lived experience offer a deeper knowledge and understanding of culturally meaningful nuances than that imparted through other formats. Medical students' lack of experiential exposure to different cultures results in communication miscues. When the stakes are high, people detect those miscues diminishing trust in the doctor-patient relationship. Greater experiential cultural exposure will enhance the facility and use of culturally specific communication cues. At its core, the requisite transformation will require medical students to adapt to other cultures and greater representation by marginalized and stigmatized populations not only among the studentry but staff and faculty. The time is now to ensure that the physicians we produce can care for all Americans. What cannot be taught must be identified by the selection process. Competence with half the population is a failure for American medicine.

"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.

The association between Situational Judgement Test (SJT) scores and professionalism concerns in undergraduate medical education

Introduction: Situational judgement tests (SJTs) are widely used in selecting medical students and doctors. Emerging evidence suggests SJTs are capable of testing an individual's ability to respond to role-relevant professionalism scenarios, however, evidence is lacking for their use in identifying students with concerning professional behaviours.This study aimed to determine the association between medical student professionalism-based SJT scores and recorded professionalism concerns during training.Methods: A cross-sectional study was conducted utilising SJT scores from second-year medical students and occurrences of student professionalism concerns. Concerns were reviewed and mapped to General Medical Council standards. Multivariate logistic regression was used to determine associations between SJT scores and professionalism concerns.Results: 247 students were included in the study. For every point increase in SJT score, students were 10% less likely to have multiple professionalism concerns [OR (95% CI) 0.90 (0.83-0.97); p = .007].Students scoring below 1 and 2 standard deviations from the mean score were 4 and 11-times more likely to have multiple concerns [OR (95% CI) 4.52 (1.12-18.25); p = .034] and [OR (95% CI) 11.45 (1.72-76.15); p = .012].Conclusion: Lower SJT scores were significantly associated with an increased risk of professionalism concerns. These findings support the potential for SJT exams to identify medical students that may require closer supervision and remediation during undergraduate education.

Assessment of medical professionalism using the Professionalism Mini Evaluation Exercise (P-MEX) in a multi-ethnic society: a Delphi study

BACKGROUND

The importance of medical professionalism and its assessment has been well documented in the literature. However, there is currently no culturally-adapted tool to assess medical professionalism in Singapore. This study sets out to find consensus on relevance of the items from the Professionalism Mini Evaluation Exercise (P-MEX) for assessing medical professionalism in Singapore.

METHODS

A two-round Delphi survey was completed by an expert panel consisting of program directors, associate designated institutional officials, and designated institutional official (n = 15) from residency programs in Singapore. Round 1 comprised of 23 items from the P-MEX rated on a 5-point scale (1 = Definitely include, 2 = Possibly include, 3 = Neutral, 4 = Possibly exclude, 5 = Definitely exclude). In round 2, the experts received feedback from the previous round, and were asked to re-rate the items which did not achieve consensus in the previous round. The threshold for consensus in the study was defined as 70% or greater agreement among experts.

RESULTS

Completed questionnaires for both rounds were received from all 15 experts. In round 1, 18 items (78%) achieved consensus to be included. In round 2, 1 (4%) item achieved consensus to be included. However, none of the remaining items achieved consensus to be removed, and they exhibited stability in responses. A list of 19 items covering four domains of medical professionalism (Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills) was obtained during the two-rounds of Delphi survey.

CONCLUSIONS

Nineteen items in the P-MEX had garnered consensus and is suitable for assessing medical professionalism in Singapore. The findings of this study can provide guidance for faculty and institutions who want to assess medical professionalism of their medical trainees.

A comparison of undergraduate teaching of psychiatry across medical schools in the Republic of Ireland

OBJECTIVES

To examine the delivery and assessment of psychiatry at undergraduate level in the six medical schools in the Republic of Ireland offering a medical degree programme.

METHODS

A narrative description of the delivery and assessment of psychiatry at undergraduate level by collaborative senior faculty members from all six universities in Ireland.

RESULTS

Psychiatry is integrated to varying degrees across all medical schools. Clinical experience in general adult psychiatry and sub-specialities is provided by each medical school; however, the duration of clinical attachment varies, and the provision of some sub-specialities (i.e. forensic psychiatry) is dependent on locally available resources. Five medical schools provide 'live' large group teaching sessions (lectures), and all medical schools provide an array of small group teaching sessions. Continuous assessment encompasses 10-35% of the total assessment marks, depending on the medical school. Only one medical school does not provide a clinical examination in the form of an Objective Structured Clinical Examination with viva examinations occurring at three medical schools.

CONCLUSIONS

Many similarities exist in relation to the delivery of psychiatry at undergraduate level in Ireland. Significant variability exists in relation to assessment with differences in continuous assessment, written and clinical exams and the use of vivas noted. The use of e-learning platforms has increased significantly in recent years, with their role envisaged to include cross-disciplinary teaching sessions and analysis of examinations and individual components within examinations which will help refine future examinations and enable greater sharing of resources between medical schools.

Teaching Professionalism in Postgraduate Medical Education: A Systematic Review

PURPOSE

This systematic review sought to summarize published professionalism curricula in postgraduate medical education (PGME) and identify best practices for teaching professionalism.

METHOD

Three databases (MEDLINE, Embase, ERIC) were searched for articles published from 1980 through September 7, 2017. English-language articles were included if they (1) described an educational intervention addressing professionalism, (2) included postgraduate medical trainees, and (3) evaluated professionalism outcomes.

RESULTS

Of 3,383 articles identified, 50 were included in the review. The majority evaluated pre- and posttests for a single group (24, 48%). Three (6%) were randomized controlled trials. The most common teaching modality was small-group discussions (28, 56%); other methods included didactics, reflection, and simulations. Half (25, 50%) used multiple modalities. The professionalism topics most commonly addressed were professional values/behavior (42, 84%) and physician well-being (23, 46%). Most studies measured self-reported outcomes (attitude and behavior change) (27, 54%). Eight (16%) evaluated observed behavior and 3 (6%) evaluated patient outcomes. Of 35 studies that evaluated statistical significance, 20 (57%) reported statistically significant positive effects. Interventions targeting improvements in knowledge were most often effective (8/12, 67%). Curriculum duration was not associated with effectiveness. The 45 quantitative studies were of moderate quality (Medical Education Research Study Quality Instrument mean score = 10.3).

CONCLUSIONS

Many published curricula addressing professionalism in PGME are effective. Significant heterogeneity in curricular design and outcomes assessed made it difficult to synthesize results to identify best practices. Future work should build upon these curricula to improve the quality and validity of professionalism teaching tools.

Nurturing professionalism in medical schools. A systematic scoping review of training curricula between 1990-2019

Introduction: Professionalism is an evolving, socioculturally informed multidimensional construct that influences doctor-patient relationships, patient satisfaction and care outcomes. However, despite its clinical significance there is little consistency in how professionalism is nurtured amongst medical students. To address this gap a systemic scoping review of nurturing professionalism in medical schools, is proposed.Methods: Levac's framework and the PRISMA-P 2015 checklist underpinned a 6-stage systematic review protocol. Concurrent use of Braun and Clarke's approach to thematic analysis and directed content analysis was used to identify the key elements in nurturing professionalism.Results: 13921 abstracts were identified from six databases, 854 full-text articles reviewed, and 162 full-text included articles were included. The 4 themes identified through thematic analysis are consistent with findings of the directed content analysis. These were the definition of professionalism, the approaches, content, barriers and enablers to teaching professionalism.Conclusion: Informed by a viable definition of professionalism and clear milestones nurturing professionalism nurturing professionalism begins with culturally appropriate training in clinical competence, humanistic qualities and reflective capacity. This process requires effective evaluations of professional identity formation, and the impact of the learning environment underlining the need for longitudinal assessments of the training process.

How to identify, address and report students' unprofessional behaviour in medical school

This AMEE guide provides a research overview of the identification of, and responding to unprofessional behaviour in medical students. It is directed towards medical educators in preclinical and clinical undergraduate medical education. It aims to describe, clarify and categorize different types of unprofessional behaviours, highlighting students' unprofessional behaviour profiles and what they mean for further guidance. This facilitates identification, addressing, reporting and remediation of different types of unprofessional behaviour in different types of students in undergraduate medical education. Professionalism, professional behaviour and professional identity formation are three different viewpoints in medical education and research. Teaching and assessing professionalism, promoting professional identity formation, is the positive approach. An inevitable consequence is that teachers sometimes are confronted with unprofessional behaviour. When this happens, a complementary approach is needed. How to effectively respond to unprofessional behaviour deserves our attention, owing to the amount of time, effort and resources spent by teachers in managing unprofessional behaviour of medical students. Clinical and medical educators find it hard to address unprofessional behaviour and turn toward refraining from handling it, thus leading to the 'failure to fail' phenomenon. Finding the ways to describe and categorize observed unprofessional behaviour of students encourages teachers to take the appropriate actions.

Perspectives about Professionalism among Undergraduate Students in a Medical College in India: A Qualitative Study

BACKGROUND

Professionalism has been recognized as an important competency of a doctor by various regulatory bodies.

OBJECTIVES

The purpose of the study was to explore the perceptions of medical undergraduate students and to assess their attitude on professionalism.

MATERIALS AND METHODS

It was a qualitative study in which four focus group discussions were conducted, one for each year of course.

RESULTS

A total of seven themes emerged after the qualitative analysis of the data, namely qualities of a good doctor, need of teaching professionalism, ways of learning professionalism by medical students, ways of teaching professionalism, assessment of professionalism, factors promoting professionalism, and factors hindering professionalism. The students perceived that a good doctor should be committed to excellence, responsive and accountable to patients, profession and community, selfless, healthy, good communicator, ethical and law abiding, practice integrity, and social justice. The students preferred to learn professionalism by role modeling by faculties and case-based scenario discussions.

CONCLUSION

Medical undergraduate students should be briefed about the need and importance of professionalism through small-group discussions involving narratives, case scenarios, and role modeling by faculty. Professionalism of both students and faculties should be assessed and appropriate action taken.

Effectiveness and feasibility of a mindful leadership course for medical specialists: a pilot study

BACKGROUND

Medical specialists experience high levels of stress. This has an impact on their well-being, but also on quality of their leadership. In the current mixed method study, the feasibility and effectiveness of a course Mindful Leadership on burnout, well-being and leadership skills of medical specialists were evaluated.

METHODS

This is a non-randomized controlled pre-post evaluation using self-report questionnaires administered at 3 months before (control period), start and end of the training (intervention period). Burn-out symptoms, well-being and leadership skills were assessed with self-report questionnaires. Semi-structured interviews were used to qualitatively evaluate barriers and facilitators for completion of the course.

RESULTS

From September 2014 to June 2016, 52 medical specialists participated in the study. Of these, 48 (92%) completed the course. Compared to the control period, the intervention period resulted in greater reductions of depersonalization (mean difference = - 1.2, p = 0.06), worry (mean difference = - 4.3, p = 0.04) and negative work-home interference (mean difference = - 0.2, p = 0.03), and greater improvements of mindfulness (mean difference = 0.5, p = 0.04), life satisfaction (mean difference = 0.4, p = 0.01) and self-reported ethical leadership (mean difference = 0.1, p = 0.02). Effect sizes were generally small to medium (0.3 to 0.6) and large for life satisfaction (0.8). Appreciation of course elements was a major facilitator and the difficulty of finding time a major barrier for participating.

CONCLUSIONS

A 'Mindful Leadership' course was feasible and not only effective in reducing burnout symptoms and improving well-being, but also appeared to have potential for improving leadership skills. Mindful leadership courses could be a valuable part of ongoing professional development programs for medical specialists.

Assessment of medical professionalism: preliminary results of a qualitative study

BACKGROUND

The importance of medical professionalism has been well documented in the literature. Cultural background affects the constituents of professionalism. However, few studies have explored the domains of medical professionalism in an Asian context. We aim to describe the views and experiences of both patients and faculty on medical professionalism in an urban Asian city state.

METHODS

Data for this qualitative study were collected through focus group discussions (FGDs) with patients and in-depth interviews (IDIs) with faculty members. The IDIs and FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using a priori framework derived from Professionalism Mini Evaluation Exercise (P-MEX). Sociodemographic data of faculty members and patients were obtained through brief questionnaires.

RESULTS

A total of 31 patients (58.1% male, all had visited healthcare facilities within the past year) and 26 faculty members (42.3% male, 38.5% from medical disciplines, median years as faculty is 11) participated in this study. The results supported the four domains of medical professionalism - Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills. Two new sub-domains which emerged from data were (1) communicated effectively with patient and (2) demonstrated collegiality.

CONCLUSIONS

The domains of professionalism in Singapore were similar to previous studies. This study allows a better understanding of medical professionalism to enhance the assessment and ultimately, the teaching of medical professionalism in an urban multi-ethnic Asian city.

Professionalism in undergraduate dental education: a pause for thought

Professionalism in dental education, as well as in the wider dental profession, is a regularly discussed and debated topic. It may seem obvious what is meant by 'professionalism' and in many situations it is clear what constitutes a professional approach or behaviour, but contention exists in how to articulate, measure and consider aspects of this complex and context dependent phenomenon. Getting 'it' right early on, with our students and new graduates, is a strategic priority, contributing to 'upstream' activities which have an intention of preventing future issues or harm. The aim of this article is to summarise the challenges faced by providers of undergraduate education (and the dental regulator) in the UK in defining and determining attainment of 'professionalism' before registration. It is timely to take an opportunity for pause, re-assess frameworks and consider future direction.

Learning medical professionalism - the application of appreciative inquiry and social media

BACKGROUND

Medical professionalism is often considered difficult to be clearly observed and learned. However, although most medical students or residents affirm the necessity of medical professionalism courses, few agree that those currently offered are adequate for a medical career.

OBJECTIVE

To develop a curriculum for teaching professionalism by enabling students to share positive examples of professionalism in social media that reflects the authentic experience in clinical environment.

DESIGN

Between October 2015 and June 2017, the authors developed a clerkship program to teach professionalism with the support of social media and appreciative inquiry. Medical students were required to write posts on the positive behaviors they observed during clinical practice in the Facebook group. Other students and course instructors commented or responded to the posted content. The content on Facebook analyzed by course instructors and was based on the definition of medical professionalism according to the 18 attributes proposed by Cruess et al. Results: In total, 103 medical students in their first clinical year participated and posted 435 records of role model learning in the Facebook group. The majority of students learned the most when the clinical instructors were passionate about their teaching and guidance in medical expertise; this accounted for 23.0% of all role model behaviors. Other attributes of professionalism that students appreciated most were being caring and compassionate (17.2%), competence (9.6%), openness (8.8%), and presence (7.7%). More than 90% of the students reported enjoying this type of course and would like to integrate their learning experiences into future behavior.

CONCLUSIONS

This innovative training program was well accepted in the formal curriculum and the predesigned social media environment. Appreciative inquiry for medical professionalism should be integrated into the organizational culture and the culture of social media interaction.

Is your mind set? - how are intra- and interpersonal competences dealt with in medical education? A multi-professional qualitative study

BACKGROUND

Professional intrapersonal and interpersonal competences (IICs) form an important part of medical expertise but are given little attention during clinical training. In other professional fields such as psychotherapy, education and aviation, training in IICs is an integral part of education and practice. In medicine, IICs tend to actually decline during studies. To date it is unclear why IICs are given less attention in medicine, despite evidence for their importance in the treatment process. In view of this, the study examined the role of IICs in the treatment process, the current situation of IIC training in medicine and, most importantly, the reasons for the comparatively low focus on IICs in the clinical training of medical students.

METHODS

Semi-structured interviews were carried out with 21 experts from a variety of medical specialties and non-medical professions that provide a training with a stronger focus on IIC development. The interviews were evaluated using grounded theory.

RESULTS

The experts confirmed the idea that IICs are an equally important component in the treatment process, along with medical knowledge and technical skills. They also described large differences between the IICs possessed by physicians but noted a general developmental need. The key shortcoming was perceived to be a deep-seated defensiveness towards learning from mistakes and deficits e.g. through reflection and feedback. The interaction of different factors that seem to be reasons for this defensiveness and perpetuate it were identified: lack of support in dealing with insecurities in the face of responsibility; the notion of medicine as a science with the categories of right and wrong answers; and a range of pressures arising from the setting, such as hierarchical, economic and competition pressures.

CONCLUSION

Our study showed, that the defensive attitude towards learning from mistakes and deficits especially in the field of IICs appears to be a subtle but powerful obstacle for implementing IICs in medical training, in contrast to other professional fields. This obstacle is sustained by various underlying barrier factors. We therefore propose that changes should be made within a cultural transformation targeting this defensive mindset and culture and its presumed reasons.

Top-cited articles in medical professionalism: a bibliometric analysis versus altmetric scores

INTRODUCTION

Citation counts of articles have been used to measure scientific outcomes and assess suitability for grant applications. However, citation counts are not without limitations. With the rise of social media, altmetric scores may provide an alternative assessment tool.

OBJECTIVES

The aims of the study were to assess the characteristics of highly cited articles in medical professionalism and their altmetric scores.

METHODS

The Web of Science was searched for top-cited articles in medical professionalism, and the characteristics of each article were identified. The altmetric database was searched to identify report for each identified article. A model to assess the relationship between the number of citations and each of the key characteristics as well as altmetric scores was developed.

RESULTS

No correlations were found between the number of citations and number of years since publication (p=0.192), number of institutes (p=0.081), number of authors (p=0.270), females in authorship (p=0.150) or number of grants (p=0.384). The altmetric scores varied from 0 to 155, total=806, median=5.0, (IQR=20). Twitter (54%) and Mendeley (62%) were the most popular altmetric resources. No correlation was found between the number of citations and the altmetric scores (p=0.661). However, a correlation was found for articles published in 2007 and after (n=17, p=0.023). To further assess these variables, a model was developed using multivariate analysis; did not show significant differences across subgroups. The topics covered were learning and teaching professionalism, curriculum issues, professional and unprofessional behaviour.

CONCLUSIONS

Altmetric scores of articles were significantly correlated with citations counts for articles published in 2007 and after. Highly cited articles were produced mainly by the USA, Canada and the UK. The study reflects the emerging role of social media in research dissemination. Future studies should investigate the specific features of highly cited articles and factors reinforcing distribution of research data among scholars and non-scholars.

Medical Students Learn Professionalism in Near-Peer Led, Discussion-Based Small Groups

Problem: Medical educators recognize that professionalism is difficult to teach to students in lecture-based or faculty-led settings. An underused but potentially valuable alternative is to enroll near-peers to teach professionalism. Intervention: We describe a novel near-peer curriculum on professionalism developed at Queen's University School of Medicine. Senior medical students considered role models by their classmates were nominated to facilitate small-group seminars with junior students on topics in professionalism. Each session was preceded by brief pre-readings or prompts and engaged students in semistructured, open-ended discussion. Three 2-hour sessions have occurred annually. Context: The near-peer sessions are a required component (6 hours; 20%) of the 1st-year professionalism course at Queen's University (30 hours), which otherwise includes faculty-led seminars, lectures, and online modules. Senior facilitators are selected through a peer nomination process during their 3rd year of medical school. This format was chosen to create a highly regarded position to which students could aspire by demonstrating positive professionalism. Outcome: We performed a qualitative descriptive evaluation of the near-peer curriculum. Fifty-six medical students participated in 11 focus group interviews, which were coded and analyzed for themes inductively and deductively. Quantitative reviews of student feedback forms and a third-party thematic analysis were performed to triangulate results. Medical students preferred the near-peer-led discussion-based curriculum to faculty-led seminars and didactic or online formats. Junior students could describe specific examples of how the curriculum had influenced their behavior in academic, clinical, and personal settings. They cited senior near-peer facilitators as the strongest aspect of the curriculum for their social and cognitive congruence. Senior students who had facilitated sessions regarded the peer teaching experience as formative to their own understanding of professionalism. Lessons Learned: Formal medical curricula on professionalism should emphasize near-peer-led small-group discussion as it fosters a nuanced understanding of professionalism for both early level students and senior students acting as teachers.

Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations

BACKGROUND

Several lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain.

METHODS

The authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students' perspectives.

RESULTS

Twenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves.

CONCLUSIONS

There are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Attitudes of faculty and residents of surgical specialties towards professionalism at a tertiary care hospital of Islamabad

Objectives:

To determine the attitudes of faculty and residents of surgical specialties towards professionalism and to test the validity and reliability of a tool developed in USA for Pakistan.

Methods:

An exploratory validation study was carried out at Pakistan Institute of Medical Sciences (PIMS), Islamabad from 01-Aug-2016 to 31-Jan-2017. Penn State College of Medicine Professionalism Questionnaire (PSCOM) was used, being a reliable and valid survey tools. Exploratory Factor Analysis of the inter-correlations of responses for 36 items was done using SPPS v 21 to give a factor solution to reflect the perceptions regarding attitudinal elements.

Results:

There were 209 respondents including 172 residents and 37 faculty members. Response rate was 81.32%. Exploratory Factor Analyses of responses gave a seven factor solution of professionalism: accountability, honour and integrity, excellence, duty, altruism, equity and respect. Six of the factors that emerged reflect the six elements of professionalism reported by American Board of Internal Medicine (ABIM), except for ‘equity’, which was the new factor that emerged. Cronbach’s alpha (Internal Consistency Reliability) for each element of professionalism was between 0.88-0.98.

Conclusion:

PSCOM is a valid, reliable, feasible and acceptable tool to assess attitudes of faculty and residents towards professionalism in Pakistan. ‘Equity’ emerged as a new factor which needs to be studied further.

Values related to professionalism in dental education at the University of Chile: Student and faculty perceptions

OBJECTIVE

It is recognised that professionalism should play a central role in dental education. However, its implementation into the curricula of dental schools is still limited. Our objective was to identify the main values related to professionalism based on the perceptions of students and faculty members from the Faculty of Dentistry, University of Chile.

METHODS

A Dental Values Survey was validated and culturally adapted in order to guarantee the greatest possible internal validity. The adapted survey was administered to students and faculty members (416 and 225, respectively). The final survey contained 64 items rated on a Likert scale of 1-5. Each item was categorised according to five dimensions: Altruism, Consciousness, Personal Satisfaction, Quality of Life and Professional Status. The values were compared between faculty and students and among students at different courses. A values scale was constructed by selecting the five items with the highest average score for each dimension.

RESULTS

Survey respondents composed 34.32% of the universe, of which 50.46% were faculty and 49.54% were students. Values associated with Altruism, Consciousness and Professional Status, were the highest rated by students and faculty. Values associated with Personal Satisfaction and Quality of Life received the lowest scores for both groups.

CONCLUSIONS

To provide the best possible attention to patients (Consciousness), and that patients have access to affordable dental care (Altruism), are the values at the top of our scale. On the other hand, to maintain financial stability and to be well paid (Quality of Life) were the less considered.

A Road Map for Attending to Medical Students' Professionalism Lapses

PURPOSE

To develop a road map for educators attending to medical students' professionalism lapses, aiming to offer an empirical base for approaching students who display such lapses.

METHOD

Between October 2016 and January 2018, 23 in-depth interviews with 19 expert faculty responsible for remediation from 13 U.S. medical schools were conducted about the way they handle students' professionalism lapses. Three researchers independently completed three rounds of coding. Data collection, coding, and analysis were performed in a constant comparative process. A constructivist grounded theory approach was used to develop an explanatory model for attending to students' professionalism lapses.

RESULTS

Based on participants' descriptions, the authors developed a three-phase approach for attending to professionalism lapses. In phase 1, experts enacted the role of concerned teacher, exploring the lapse from the student's perspective. In phase 2, they functioned as supportive coach, providing feedback on professionalism values, improving skills, creating reflectiveness, and offering support. In phase 3, if the student did not demonstrate reflectiveness and improvement, and especially if (future) patient care was potentially compromised, participants assumed an opposite role: gatekeeper of the profession.

CONCLUSIONS

An explanatory model for attending to professionalism lapses that fits in the overarching "communities of practice" framework was created. Whereas phase 1 and 2 aim at keeping students in the medical community, phase 3 aims at guiding students out. These findings provide empirical support to earlier descriptive, opinion-based models and may offer medical educators an empirical base for attending to students who display professionalism lapses.

Delivering to 'that list': the challenges of working with learning outcomes

Dental education providers have raised concerns around the challenges experienced when trying to demonstrate student attainment of 'professionalism', as described in the General Dental Council (GDC) document 'Preparing for practice'. This manuscript describes a documentary analysis of each 'outcome' within the dentist professionalism domain section, with an assessment of whether it met the criteria of a functional learning outcome. In addition, outcomes were scrutinised in terms of application within undergraduate degree programmes. Key challenges identified were: the 'outcome list' included standards and objectives as well as outcomes; not all statements were specific and focused, some were broad and multi-faceted; determining attainment where there was no identifiable endpoints; and judging achievability within the supervised and confined environment of undergraduate programmes. We conclude that issues have been created through the way that these learning outcomes have been expressed. Also, it is evident that there are ideological and philosophical issues about accurately articulating the attainment of complex phenomena like professionalism. The findings from this study reflect the challenges associated with using learning outcomes to adequately capture professionalism, the values that underpin it and the behaviours that manifest its existence in clinical practice.

First Year Medical Student Peer Nominations of Professionalism: A Methodological Detective Story about Making Sense of Non-Sense

This article explores the assessment of professionalism within a cohort of medical students during a sequential 13-week medical school histology and anatomy course. Across seven data points, students were asked to identify a professionalism role model from amongst their peers and to score Likert-structured rationales for their decision. Based on density scores, an initial social network analysis identified six peer-nomination "stars." However, analysis of these stars revealed considerable variability and random-like "noise" in both the nomination and explanation data sets. Subsequent analyses of both data sets explored the possibility of underlying patterns in this noise using tests of reliability, principal components factor analysis, and fixed-effects regression analysis. These explorations revealed the presence of two dimensions (professional vs. supportive) in how students sought to explain their nomination decisions. Although data variability remained quite high, significantly less variability was present in the professional than in the supportive dimension, suggesting that academic helpfulness rationales are both empirically distinct and more mutable than rationales grounded in professionalism-related factors. In addition, data showed that the greater the stability in one's choice of a professionalism role model nomination over the T1-T7 data periods, the more stable one's reasons for that nomination-both for professionalism and supportive dimensions. Results indicate that while peer assessment of professionalism by first-year medical students may not be very reliable, students can differentiate between more personal and professional factors, even at this early stage in their professional development. Formal instruction within the pre-clinical curriculum should recognize and address this distinction. Anat Sci Educ. © 2018 American Association of Anatomists.