Assessment of professionalism in medical students during a ... · Assessment of professionalism in...

Assessment of professionalism in medical students during a longitudinal primary care

clerkship

Page | 1Damian Meli, Angie Ng, Regina Ahrens, Severin Lüscher, and Mireille Schaufelberger

MedEdWorld Publish www.mededworld.org

Title: Assessment of professionalism in medical students during a longitudinal primary care

clerkship

Authors:

Damian N. Meli, Angie Ng, Regina Ahrens, Severin Lüscher, Mireille Schaufelberger

Institute of Family Medicine, University of Bern, Switzerland

Notes on Contributors:

Damian N. Meli, MD, PhD, is a General Practitioner and Clinical Researcher at the Bernese

Institute of Family Medicine.

Angie Ng, MA, is Social Scientist and PhD Student.

Regina Ahrens, MD, is a General Practitioner and Teaching Coordinator at the Bernese

Institute of Family Medicine.

Severin Lüscher, MD is a General Practitioner in Schöftland, Switzerland.

Mireille Schaufelberger is a General Practitioner and Head of the Bernese Institute of Family

Medicine of the University of Bern.

Corresponding Author:

Dr. med. Mireille Schaufelberger

Bernese Institute of Family Medicine (BIHAM)

University of Bern

Murtenstrasse 11

3010 Bern

Switzerland

E-mail: [email protected]

Declaration of Interests

The authors report no declarations of interest.


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Abstract

Introduction: Professionalism is an essential theme in both medical education and clinical practice.

As discussion and research on this topic has mainly taken place in Anglo-Saxon countries, this

study uses data from the longitudinal primary care clerkship

at the medical school of the University of Bern in Switzerland.

Methods: Questionnaires completed by GP teachers on their medical students were evaluated for

first- to fourth-year students.

Results: Results suggest that students show improved professionalism from year to year. They also

show that particular areas of professionalism warrant particular attention.

Conclusion: Professionalism should be assessed regularly in medical schools so that guidance can

be provided concerning specific areas that require attention. GP clerkships may be ideal for

assisting students in improving their professionalism before clinical practice. The vast majority of

students exhibit attitudes and behaviours associated with professionalism, but there are certain

aspects for which training would be especially useful.



Practice Points:

According to current literature, we found that most medical students have a high level of

professionalism; however, there seems to be a small but a conspicuous group of students

who require intervention.

We recommend that professionalism should be assessed regularly in medical schools so that

students who exhibit unprofessional behaviours and/or attitudes can receive special guidance

and improve this aspect as early as possible in their schooling.

Findings suggest that longitudinal GP clerkships may be useful to develop professionalism

skills and to identify students who require intervention.


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Introduction

Over the past two decades, professionalism has emerged as an essential theme in both clinical

practice and medical education, featured in medical education conferences and journals (Hodges et

al, 2011). How to teach, assess and evaluate professionalism has become an intensely discussed

topic in medical education (McLachlan et al. , , 2009). Unprofessional behaviour during medical

school has been linked with disciplinary action by medical boards, especially severe lack of

responsibility and capacity to improve oneself (Papadakis et al., 2005).

According to Howe et al., 2010, previous studies illustrate that very few students exhibit

unprofessional behaviour strong enough to warrant a formal warning, three percent in their study,

and the numbers decrease as students move into their senior years. To date, there is little evidence

of interventions that effectively change attitudes towards professionalism over the long term (Jha et

al, 2007); however, Howe et al. (2010) suggest that clear guidance and early “low-level” warnings

helped medical students avoid repeating unprofessional behaviour.

Discussion and research has taken place predominantly in Anglo-Saxon contexts (ibid.), and yet,

there is no general consensus among medical schools concerning what the most important non-

academic attributes of a good doctor are even within, for example, the UK (Lambe and Bristow,

2010). Not surprisingly, there is yet to be an internationally-agreed upon set of elements that define

professionalism (Hodges et al, 2011).

Some definitions

Cruess et al. (2006) found that the following four main factors were involved in professionalism:

(1) doctor-patient relationship skills; (2) reflective skills, (3) time management and (4) inter-

professional skills. They developed the Professional Mini-Evaluation Exercise (P-Mex) using the

format of the existing mini-Clinical Examination Exercise (mini-CEX) (ibid).

Based on an extensive literature review, Wilkinson et al. (2009) found that there were various


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themes and sub-themes that can define professionalism. These include but are not limited to the

following: (1) observing ethical principles, such as honesty, confidentiality and moral reasoning; (2)

behaving effectively towards patients and those important to them, including respect for diversity,

courtesy, patience, empathy and common manners; (3) interacting with other health care workers in

a polite fashion; (4) reliability, including accountability, punctuality, taking responsibility and being

organised; and (5) commitment to autonomous maintenance and continuous improvement of

competence in self, others and systems, including responding to error and lifelong learning (ibid.).

Lambe and Bristow (2010) conducted a Delphi survey of clinicians and found that the ten most

important core attributes of a good doctor were the following: recognition that patient care is the

primary concern of a doctor; probity (being honest, trustworthy and acting with integrity), good

communication and listening skills; recognition of one's own limits and those of others; pro-social

attitude (empathy without judgement), ability to cope with ambiguity, change, complexity and

uncertainty; commitment to lifelong learning, competence and performance development;

compassion; motivation and commitment; and ability to be a team player.

McLachlan et al. (2009) identified six key principles with the General Medical Council's Good

Medical Practice. These are as follows: (1) make the care of the patient the doctors' first concern;

(2) protect and promote the health of patients and the public; (3) ensure a good standard of practice

and care; (4) respect patient's individuality and dignity; (5) work in partnership with patients; and

(6) practising medicine with honesty, openness and integrity (ibid).

Hodges et al. (2011) found that professionalism is fundamentally linked to the social responsibility

of the medical profession. They found that existing literature defined professionalism in the

following three different ways: individual, interpersonal and societal/institutional (ibid); for each of

these, they provided recommendations for assessment of professionalism.


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Measurement Tools

There are numerous methods used to measure professionalism, and reviewing these methods,

Wilkinson et al. (2009) developed a toolbox for this purpose. This study will use multiple tools

from this selection.

Assessment of observed clinical encounter:

The mini-Clinical Evaluation Exercise (mini-CEX) has been used to assess 15- to 30- minute

observations of authentic doctor-patient interactions using a standardised marking sheet, and the P-

Mex, developed by Cruess et al (2006), has been specifically developed to look at different aspects

of professionalism (Wilkinson et al. 2009).

Multisource Feedback (MSF) – co-workers:

The person being assessed typically nominates 10 to 20 co-workers, for example, consultants, allied

health professionals and clerical staff, to provide feedback on their performance, skills and

behaviours (Wilkinson et al. 2009).

Patients' opinion:

This is a direct survey of the end-users of a service and hence important; however, this method

should not be used as a stand-alone method; instead, results should always be interpreted in

conjuction with other methods and keeping in mind characteristics of the population being surveyed

(Wilkinson et al. 2009).

Self-administered rating scale:

Questionnaires containing these rating scales are used by individuals to assess themselves; one such

scale is the Penn State College of Medicine Professionalism Questionnaire (Wilkinson et al. 2009).

However, the purpose is more to aid reflection since it does not access how a person actually

performs (Wilkinson et al. , 2009).


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Background - Early Clinical Exposure System

The medical school of the University of Berne in Switzerland implemented a mandatory

longitudinal integrated clerkship in primary care in 2007. In their first three years of medical school,

(out of a total of six years training), students experience eight half days each year with a GP who

acts as a mentor. In their fourth year, students stay with the same GP for three weeks

(Schaufelberger et al., 2009). The program promotes clinical and communication skills through

early contact with patients and helps improve students' professionalism (ibid). The strength of this

system, in terms of professionalism, is that, for these four years, each student has her/his own

mentor over time, who is in the unique position to not only serve as a role model but also help

identify issues in this area and provide guidance.


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Methods

This study used data collected from GP mentors of medical students in their first, second, third and

fourth years of medical school from 2009 to 2011; this data was obtained as part of the clinical

exposure programme's feedback system. As part of the programme, GPs are required to sign for the

completion of each training period, and in order to do so, they are required to fill out an assessment

form for the students. This method was referred to by Wilkinson, Wade and Knock (2009) as global

view of supervisor. Statistical analysis was carried out with SPSS v. 19.

The study is longitudinal in that students in their first, second and third years in 2009-2010 are

those in their second, third and fourth years in 2010-2011.

Instruments

The instruments used to evaluate students are questionnaires that are part of the existing feedback

system for the programme. First- to third-year students are evaluated with one questionnaire, and

fourth-year students are evaluated with an expanded version which contains more questions

concerning factors of professionalism in order to get a more nuanced view.

First- to Third-Year Students:

For first- to third-year students, there is a general questionnaire for the GPs to fill in about their

students. This questionnaire contacts one item relevant to our study, Social and Communicative

Competence, for which they must select whether the student has completely, partially or not

fulfilled this criteria. Social and communicative competence here are defined for the respondents as

follows: (1) approaching patients and showing empathy, respect, helpfulness and tolerance towards

them; (2) speaking in a manner that is intelligible to patients; (3) integrating oneself into the


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practice team; and (4) being able to accept criticism.

Fourth-Year Students:

For fourth-year students, the survey contains a section for professionalism comprised of 19 items,

many of which correspond with the definition of professionalism detailed in the above paragraph.

Seven of these measure attitudes, such as motivation and concentration; nine measure social

competence, including helpfulness and tolerance; and three measure communicative competence,

for example, approaching the patient. For each item, the respondents were asked to select whether

students were (1) under expectations, (2) meeting expectations or (3) over expectations. Seen as a

scale, this instrument is highly reliable, with a Cronbach's Alpha of 0.934. The specific questions in

the questionnaire are shown in Table 1.


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Results

First- to Third-Year Students:

The data collected for the two student classes which could be compared across the school years

2009-2010 and 2010-2011 is summarised in Table 2. For both 2009-2010 and 2010-2011, there

were no students who did not fulfil the criteria for communicative competence (not shown). The

level of those who completely fulfilled the criteria was consistently high for all groups, ranging

from 97.78% to 100%. Although the numbers are not statistically significant, it appears that there is

a general trend for increases in the percentage of students who completely fulfil the criteria as the

same class moves from year to year. The first-year class of 2009-2010 improved their rate of

complete fulfilment from 98.01% as first-year students to 98.72% as second-year students; the

second-year class of 2009-2010 saw their completely fulfilment rate rise from 97.78% to 100%.

Fourth-Year Students:

The questionnaires of 303 medical students were analyzed. Regarding Attitude, recognising one’s

strengths and weaknesses received the lowest percentage ranked as exceeding expectations (53.5%)

while motivation received the highest percentage (77.9%) (Figure 1A). Ratings under expectations

were only received for motivation (0.3%), perseverance (0.7%) and recognising one’s strengths and

weaknesses (0.3%). The histogram shows that the largest number of students, nearing 100, received

the highest possible total score in this area, a score of 21 (Figure 1B). The frequency then makes a

sudden drop and plateaus at just below 40 for scores of 18 to 20 before dropping to below 10 at the

score of 15; the frequency for the score 14, however, jumps back to around 35.

There are less than five students who received a score of 13.

Looking at Social Competence, accepting criticism received the lowest percentage ranked as

exceeding expectations (46.2%) while exhibiting interest received the highest percentage (84.5%)

(Figure 1C). Ratings under expectations were only received for recognising the patients’ needs


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(0.3%), keeping the correct proximity to patients (0.3%) and accepting criticism (0.3%). The

histogram is similar to that of the Attitude items. It shows that the largest number of students,

above 100, received the highest possible total score in this area, a score of 27 (Figure 1D). The

frequency seems to suddenly drop at the next score, 26, and plateau at 20 students over scores of 22

to 26 before dropping to below 10 at the score of 19 and 20; the frequency for the score 18,

however, jumps back to roughly 20. There are less than five students who receive a score of 15.

In Communicative Competence, communicating in different languages received the lowest

percentage ranked as exceeding expectations (48.6%) while approaching the patient received the

highest percentage (77.9%) (Figure 1E). Ratings under expectations were received for

communicating in different languages (0.7%) and speaking intelligibly (0.3%)

The histogram is similar to that of the Attitude and Social Competence items. It shows that the

largest number of students, above 100, received the highest possible total score in this area, a score

of 9 (Figure 1E). However, the scores do not plateau but just drop until reaching less than 10

students at a score of 5.


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Discussion

Research Instruments

The tool to assess first year students has a concrete definition of what is expected in professional

behaviour, specifically with regards to social and communicative competence, which is in

accordance with current literature; however, using just one question to measure professionalism

obviously does not give an adequately nuanced view of the students, but may be sufficient for the

identification of the obviously suspicious students and adequate for an observation time of 8 half

days.

The questionnaire of the fourth year students contained many elements that previous literature has

identified as being important to professionalism, suggesting that professionalism in Switzerland

may be very similar to that in Anglo-Saxon countries. For example, it contains 3 or 4 factors

mentioned in Cruess et al. (2006).

The scale's high reliability shows its potential for use in future studies in other parts of Switzerland

as well as other geographical areas. However, before that is done, there appears to be an

overlap/duplication of certain questions, such as Q13 and Q16, showing that the scale could be

shortened by eliminating the duplicate items.

Also item Q19, the ability to speak in different languages, may be useful, it does not necessarily

reflect the ability of intercultural communication. Further research is required to show whether or

not, taking into account migration, this item is important as an aspect of professionalism in other

contexts.

Findings in First- to Third-Year-Students

As previous studies have also found, the majority of students do not exhibit enough behaviours


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and/or attitudes associated with being unprofessional to warrant low ratings. Since the results,

though statistically not significant, seem to point to each classes' improving in professionalism with

the number of years of GP mentorship experienced; this suggests that early exposure to patients and

the clinical environment, along with having a personal mentor, can assist students' in developing

professional behaviour and attitudes and ameliorating any unprofessional ones. Indeed, as mentors

stay with the students through their four clinical experience terms, they are well positioned to be

able to detect unprofessional attitudes and behaviour and provide feedback and support to students.

In cases where students may not be considered well-suited for clinical work, it may be suggested to

them that they pursue alternative careers such as non-clinical, administrative, or research work.

Findings in Fourth-Year Students:

As in the results for the first- to third-year students, the data shows that the vast majority of students

exhibit attitudes and behaviours associated with professionalism; this is in agreement with the

current literature.

The data from the fourth-year students shows that only items 1, 3, 5, 9, 12, 14, 18 and 19 received a

rating of “under expectations”, and the percentage of students rated as such was very low, from

0.3% to 0.6%. Interestingly, instead of frequency counts tapering off at the lower end of the scoring

spectrum, there are a group of students who curiously and obviously score lower than the others

score, with a small number of these scoring even lower than the rest of the students in this group.

This suggests that there is a collection of students in each year with especially low professionalism.

These students would benefit from interventions, and if no improvement is shown, they should

receive career counselling and be advised to pursue research careers instead of clinical ones.

The data reveals that the same items consistently show 40+% or 30+% of students' being rated as

just meeting expectations, indicating that these are special points that need improvement. These can


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be the focal points for interventions in improving professionalism. The points are listed in Table 3.

Many of the points which this study has found to be consistently challenging to fourth-year students

are especially important in clinical practice, such as speaking in a manner that is intelligible to

patients.

Limitations

This study would be improved by incorporating evidence from other types of assessment, especially

those taking into account the views of more than one observer (Wilkinson, et al. 2009), such as

other medical co-workers and patients.

Using the same method, it would be more helpful if the same instrument would be used to measure

both fourth year students' professionalism and that of the other students in order to make it possible

to compare longitudinally, which is preferable to measurements carried out at a single point in time

(Wilkinson et al. 2009). More feasible, perhaps, would be that this instrument were shortened for

first- to third-year students, in which case the results could be compared for the questions which

exist in both the shortened and original questionnaires. Jha et al (2007) noted that there were few

studies reporting measurement tools that could be used longitudinally, and with is validity, this is

one tool that could carry out this function if applied to student in all years of study, every year.

Following the same students further into their careers would provide evidence of whether or not

exhibiting unprofessional behaviours and/or attitudes during medical school is correlated with

negative behaviours once the students are practitioners.


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Conclusion

This paper has found that, matching current literature, most medical students have a high level of

professionalism. However, there seems to be a conspicuous group of students who require

intervention. This research has located areas which require special attention from medical students

in general, and training in these areas would benefit all students and especially those who require

intervention.

This research has found that professionalism should be assessed regularly in medical schools so that

students who exhibit unprofessional behaviours and/or attitudes can receive special guidance and

improve this aspect as early as possible in their schooling so that they can achieve maximal

improvement before practising medicine. The measurement instrument used in fourth-year students

should either be used in whole or shortened for use in first- to third-year students to allow for

longitudinal comparison; it is also recommended that assessment of professionalism come from

additional sources and not just the GP mentor. This research instrument could also be used in non-

Swiss settings, but further research is required to determine whether or not the item, ability to speak

other languages, is important in other contexts.

That being said, findings suggest that GP clerkships are ideal for students to develop professional

skills. Mentors are also in the best position to detect conspicuous lack of professionalism and

provide special guidance to students in this category and recommend them for additional training in

this area. As lack of professionalism in medical school has been linked to unprofessional behaviour

in clinical practice in other studies, students who cannot improve in this regard should be advised to

pursue non-clinical careers in research.


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References

Cruess, R., McIlroy, J.H., Cruess, S., Ginsburg, S. and Steinert, Y. (2006). The Professionalism

Mini-evaluation Exercise: a preliminary investigation. Academic Medicine: 81(10 Suppl): S74-8.

Doukas, D.J., McCullough, L.B. and Wear, S. (2012) Perspective: Medical Education in Medical

Ethics and Humanities as the Foundation for Developing Medical Professionalism. Academic

Medicine: 87(3), pp. 334-340.

Hodges, B.D., Ginsburg, S., Cruess, R., Cruess, Sl, Delport, R. Haffertyy, F. Ho, M.-J., Holmboe, E.

Holtman, M., Ohbu, S., Rees, C., Cate, O.T., Tsugawa, Y., Van Mook, W., Wass, V. Wilkinson, T.

and Wade, W. (2011). Medical Teacher: 33, e354-e363.

Howe, A., Miles, S., Wright, S., and Leinster, S. (2010) Putting theory into practice - A case study in

one UK medical school of the nature and extend of unprofessional behaviour over a 6-year period.

Medical Teacher: 32(10), pp. 837-844.

Jha, V., Bekker, H.L., Duffy, S.R.G., and Roberts, T.E. (2007) A systematic review of studies

assessing and facilitating attitudes towards professionalism in medicine. Medical Education: 41(8),

pp. 822-829.

Lambe, P. and Bristow, D. (2010) What are the most important non-academic attributes of good

doctors? A Delphi survey of clinicians. Medical Teacher: 32(8), e347-e354.

McLachlan, J.C., Finn, G., and Macnaughton, J. (2009) The Conscientousness Index: A Novel Tool


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to Explore Students' Professionalism. Academic Medicine: 84(5), pp. 559 - 565.

Papadakis, M.A., Teherani, A., Banach, M.A., Knettler, T.R., Rattner, S.L., Stern, D.T., Veloski, J.J.

and Hodgson, C.S. (2005) Disciplinary action by medical boards and prior behaviour in medical

school. New England Journal of Medicine: 353(25), pp. 2673-2682.

Schaufelberger, M., Trachsel, S., Rothernbühler, A. and Frey, P. (2009) Eine obligatorische

longitudinale Ausbildung von Studierenden in 530 Grundversorgerpraxen. GMS Zeitschrift für

Medizinische Ausbildung: 26(2), Doc21. [Online] Available at:

http://www.egms.de/static/de/journals/zma/2009-26/zma000613.shtml [Accessed 15.04.2012]

Tsugawa, Y., Ohbu, S., Cruess, R., Cruess, S. Okubo, T., Takahashi, O., Tokuda, Y., Heist, B.S.,

Bito, S., Itoh, T., Aoki, A., Chiba, T. and Fukui, T. (2011) Introducing the Professionalism Mini-

Evaluation Exercise (P-MEX) in Japan: Results From a Multicenter, Cross-Sectional Study.

Academic Medicine: 86(8), pp. 1026-1031.

Wilkinson, T.J., Wade, W.B., and Knock, L.D. (2009) A Blueprint to Assess Professionalism:

Results of a Systematic Review. Academic Medicine: 84 (5), pp. 551-558.


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Figures and Tables

Table 1: Questionnaire items

Items Questions

Motivation 1 Attitude

Asking questions 2

Shows perseverance/concentration 3

Accepts challenges 4

Recognises one's own strengths and weaknesses 5

Ability to differentiate between the relevant and irrelevant 6

Recognises relationships between things 7

Exhibits interest 8 Social

Competence Recognises the patients' needs 9

Helpfulness 10

Tolerance 11

Keeping the correct proximity to patients 12

Accepts criticism 13

Knows one's own limitations 14

Integrates oneself into the practice team 15

Accepts feedback/criticism 16

Approaches the patient 17 Communicative

Competence Speaking intelligibly 18

Communicates in different languages 19


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Table 2: Student fulfilment of criteria for social and communicative competence

First Year

2009-2010

Second Year

2010-2011

Second Year

2009-2010

Third Year

2010-2011

Completely

fulfilled

98.00% 98.72% 97.78% 100.00%

Partially

fulfilled

1.32% 1.28% 2.22% 0.00%


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Figure 1: Bar Charts and Histograms of scores for professionalism items in questionnaire for

fourth-year students

Figure shows the pooled results of fourth year students of the classes 2009/2010 and

2010/2011: A) Attitude Question 5 received the lowest percentage ranked as exceeding expectations

while Q1 received the highest percentage. B) The attitude histogram shows that the largest number

of students received the highest possible total score in attitude. C) Social Competence Question 13

received the lowest percentage ranked as exceeding expectations while Question 8 received the

highest percentage. D) Social Competence histogram. E) Communicative Competence Question 19

received the lowest percentage ranked as exceeding expectations while Q17 received the highest

percentage. F) Communicative Competence histogram.


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Table 3: Special points that need improvement

Items

Q5: Recognising one's own strengths and weaknesses

Q6: Differentiating between the relevant and irrelevant

Q13: Accepting criticism

Q19: Speaking other languages

Q2: Asking questions

Q7: Recognising relationships between things

Q12: Keeping the appropriate proximity to patients

Q14: Understanding one's own limitations

Q18: Speaking in a manner that is intelligible to patients

Percentage of students only rated “Meets expectations”: 40% and 30%

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