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Medical professionalism: can it and should it be measured?

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4716 (Published 18 November 2009) Cite this as: BMJ 2009;339:b4716
  1. Naomi Engel, fourth year medical student,
  2. Jennifer Dmetrichuk, fourth year medical student,
  3. Anne-Marie Shanks, fourth year medical student
  1. 1School of Medicine and Dentistry, The Suttie Centre for Teaching and Learning in Healthcare, Foresterhill, Aberdeen AB25 2ZD
  1. naomi.engel.06{at}aberdeen.ac.uk

Abstract

Naomi Engel, Jennifer Dmetrichuk, and Anne-Marie Shanks define professionalism, explore why it is important now, and discuss how it may develop in the future.

Professionalism in medicine is attracting increasing attention from students, doctors, and the media. Medical professionalism can essentially be defined as a set of values, behaviours, and relationships.1 Specifically, this includes integrity, compassion, altruism, continuous improvement, excellence, and working in partnership with members of the wider healthcare team.1

The authors of a US study suggested 68 behaviour based signs of professionalism, derived from focus groups among patients, nurses, and doctors.2 This study showed a wide gap between focus groups in the perceived importance of aspects of professionalism. For example, 79.4% of patients deemed “preparing before seeing the patient” a very important aspect of professionalism, compared with only 35.1% of doctors.2 Surprisingly, dress did not meet the criteria for importance as a behavioural sign of professionalism.2 This finding is notable because the General Medical Council (GMC) in the United Kingdom states that students and doctors should dress in an “appropriate and professional way.”3 This contradiction thus highlights the difficulty in comprehensively defining medical professionalism.

Professionalism today

Currently, unprecedented challenges are arising from the increasing expectations of professionalism from patients, healthcare managers, and government.4 The Royal College of Physicians says that medical professionalism is more relevant now than ever before, partly because of recent high profile cases that have highlighted poor professionalism.1 In fact, most complaints to the GMC are about doctors’ behaviour, not their lack of knowledge.5 This shows the importance of redefining and developing professionalism in today’s undergraduates.

Four key opportunities for learning professionalism have been suggested—role models; formal curriculum; prior life experience and background; and experiential learning.6 Students perceive role models, a part of the informal curriculum, as the most important influence on their development of professionalism.6 Yet a study of 665 third and fourth year medical students in the US found that 98% had witnessed “unprofessional behaviour” among their teaching faculty.7 In the UK, guidance documents on defining and developing professionalism have been published by several organisations, including the Royal College of Physicians,1 the King’s Fund,5 and the GMC.89 Professionalism is now a required competency throughout the continuum of undergraduate and postgraduate medical education.6

How can professionalism be assessed?

Recently, Professor John McLachlan and colleagues developed the conscientiousness index, which they claim can objectively assess professional behaviour in medical students.10 The index was applied to 116 first and 108 second year students at Durham University. The index awards or deducts points for attendance at compulsory sessions; submission of data (for example, a criminal record); submission of evaluative feedback; completion of summative assessments and assignments; voluntary participation at university events; and uncategorised events (for example, failing to respond to repeated emails from staff or attending a teaching session in an unfit state). This resulted in the students gaining a score and a ranking of conscientiousness. The scores correlated well with staff perceptions of student professionalism and critical incidents reports, giving strength to the index’s validity. The second year students seemed to be slightly more conscientious than the first year students, indicating that this is a trait that can be learnt, perhaps through role models.

Although assessing professionalism is not new, the index is the first tool that attempts to measure it objectively. The index was developed on the basis of evidence that linked negative student behaviour during undergraduate programmes to subsequent adversities in later careers.10 For example, in the US, a link was found between problematic medical students and later disciplinary action by the state board.11 Also, medical students at the University of Sheffield who did not comply with a simple administrative task were found more likely to struggle and fail their exams.12 This is in keeping with a cohort study from Nottingham that showed conscientious students were more likely to have higher A level grades and do better in preclinical assessments13; however, they performed less well in clinical assessments. This raises the question of the validity of the conscientiousness index in assessing professionalism holistically.

Arguments against assessing professionalism

“Overly intrusive assessment” of professionalism has been met with concern and anger from medical students (BMA Medical Students Committee, personal correspondence, 14 September 2009).141516 Student leaders at the BMA were concerned to hear that students have been disciplined for trivial non-medical misdemeanours.17 They cite examples such as playing loud music or having a messy kitchen in halls. However, the conscientiousness index does not assess such behaviours. Being punished for minor events occurring in the student’s own time is quite different from receiving a poor index mark for failing to attend compulsory lectures. Although some feel that the index introduces an element of “big brother” monitoring medical school conscientiousness, the criteria do not incorporate aspects of students’ personal or social life.

Some medical students still argue that the index is not necessary—students who are behaving unprofessionally enough to warrant a fitness to practise hearing will be identified by the medical schools’ existing disciplinary policies. Some think that there is no need to introduce a formal assessment scale. Furthermore, there is as yet no evidence that shows that medical students who score low on the index automatically become unprofessional doctors (JC McLachlan, personal correspondence, 2 September 2009). Another potential concern is the apparent inability of the index to assess disabled students accurately. Students with declared disabilities were often perceived by staff to be showing good professionalism, but their scores were low.10

Some argue that conscientiousness is only a minor component of professionalism, and that a more holistic approach to assessment is required. Assessing professionalism as a whole is difficult for many reasons. Firstly, no consensus on the definition exists. Secondly, professionalism encompasses many different and varied components. And finally, some of these components such as altruism, integrity, and compassion are difficult to assess objectively. The reliability and validity of the conscientiousness index are questionable, but is assessment of other aspects of professionalism likely to be any better?

The BMA Medical Students Committee says that “patient care and safety should be the top priority in any analysis of medical student professionalism. Medicine by definition is too varied and complex a specialty to be considered a ‘tick box exercise’. We must remember that medical students are developing as professionals and some may make errors of judgment, especially early in their careers. This is one of the many reasons why medical students work under such close supervision of other qualified doctors” (BMA Medical Students Committee, personal correspondence, 14 September 2009).

The future of professionalism

With this controversy, it is difficult to anticipate whether such assessments will ever be implemented. It has been reported that 50% of medical schools have written criteria in place in addition to specific assessments for professional behaviour.18 Whether or not a full conscientiousness index type assessment will be implemented to continually monitor professionalism has yet to be determined. It is likely that the definition of professionalism will need to be solidified before it can be accurately assessed. Assessment tools will need to be further developed to determine their validity and maximise their applicability. McLachlan says that additional research will take years or possibly decades to strengthen.10 In the future, he and his team intends to trial the conscientiousness index as a tool for self improvement through formative feedback rather than for disciplinary actions (JC McLachlan, personal correspondence, 2 September 2009).

Students will soon have the chance to express their views on professionalism. A joint project hosted by the Royal College of Physicians, the GMC, the King’s Fund, and others will be taking a road show to many UK medical schools over the next three years. These follow the success of previous road shows for doctors, which resulted in the influential report Understanding Doctors; Harnessing Professionalism.19 The student road shows will be attended by medical leaders and will consist of roundtable discussions on professionalism and a question and answer session with an expert panel. The discussions will be recorded to provide the content of the next report, which will consider professionalism for students. The organiser from the Royal College of Physicians, Susan Shepherd, says “although light hearted, the road shows have a serious intent. Information coming from the shows will help to shape medical practice for the next generation. So if you have an opportunity to attend, please do so. We are keen to hear your views” (S Shepherd, personal correspondence, 9 September 2009).

Whatever your opinions on professionalism, it is likely to be something we will all hear more about in the future. Both formal teaching and assessment are possibilities, yet considerable uncertainty remains about the validity and viability of these measures. Promotion of professionalism among medical students is a worthwhile initiative, but welfare of both students and patients must remain paramount.

Footnotes

  • Competing interests: None declared.

References