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Research questionResearch question
What do medical students and Doctors What do medical students and Doctors understand by the term understand by the term “professionalism”?“professionalism”? This matters because medical students This matters because medical students
are expected to develop as professionalsare expected to develop as professionals are tutor assessed are tutor assessed
Does their understanding change during Does their understanding change during their training?their training? Does Perry apply?Does Perry apply?
Dualism, relativism, comfortDualism, relativism, comfort Can we influence the rate of development?Can we influence the rate of development? Can we develop an inventory, or use an Can we develop an inventory, or use an
existing one?existing one? Would peer assessment work?Would peer assessment work?
What is knownWhat is known
Scribonius 47CE Scribonius 47CE The profession of medicine is The profession of medicine is
defined as a commitment to defined as a commitment to compassion or clemency in the compassion or clemency in the relief of suffering.relief of suffering.
Pellegrino 2002Pellegrino 2002 A profession is a public statement A profession is a public statement
of commitmentof commitment The doctor and the patient are in a The doctor and the patient are in a
covenantal relationshipcovenantal relationshipPellegrino, E.D., Professionalism, profession and the virtues of the good physician. Mt Sinai J Med, 2002. 69(6): p. 378-84 Philosophical discourse
RCP DefinitionRCP Definition
Medical professionalism Medical professionalism signifies a set of values, signifies a set of values, behaviours, and relationships behaviours, and relationships that underpins the trust the that underpins the trust the public has in doctorspublic has in doctors
Royal College of Physicians, Doctors in Society:Medical professionalism in a changing world. 2005, RCP: London. Interviews and expert group analysis
RCP DescriptionRCP Description
Medicine is a vocation in which a Medicine is a vocation in which a doctor’s knowledge, clinical skills, doctor’s knowledge, clinical skills, and judgement are put in the and judgement are put in the service of protecting and service of protecting and restoring human well-being. This restoring human well-being. This purpose is realised through a purpose is realised through a partnership between patient and partnership between patient and doctor, one based on mutual doctor, one based on mutual respect, individual responsibility, respect, individual responsibility, and appropriate accountability.and appropriate accountability.
Doctors are committed Doctors are committed to:to:
IntegrityIntegrity CompassionCompassion AltruismAltruism Continuous improvementContinuous improvement ExcellenceExcellence Working in partnership with Working in partnership with
members of the wider healthcare members of the wider healthcare team.team.
Justice Potter StewartJustice Potter Stewart
I know it when I see it.I know it when I see it.
obscenityobscenity
Attitudes and values Attitudes and values Professional qualitiesProfessional qualities Professional Professional
behaviour behaviour Professional habitsProfessional habits Professional attitudes Professional attitudes Professional Professional
demeanourdemeanour Professional Professional
attributes/traits attributes/traits
Cohen 2001Cohen 2001
Personal Personal qualities/personality qualities/personality
Personal Personal characteristicscharacteristics
Psychosocial factorsPsychosocial factors Hard to assess Hard to assess Non-cognitive factorsNon-cognitive factors
Cohen, R., Assessing professional behaviour and medical error. Med Teach, 2001. 23(2): p. 145-151. Cohen calls for direct observation of clinical performance – but what criteria?
Association for Surgical Education: Clinical Association for Surgical Education: Clinical Evaluation Protocols for Medical Students, Evaluation Protocols for Medical Students,
1985.1985.
QualityQuality % of schools% of schools
Relationship with patientsRelationship with patients 8282
Motivation Motivation 8181
Relationship with team membersRelationship with team members 7272
Relationship with teachersRelationship with teachers 5757
ResponsibilityResponsibility 4040
DependabilityDependability 3636
PunctualityPunctuality 2929
AppearanceAppearance 2525
Peer relationsPeer relations 2020
Integrity/honestyIntegrity/honesty 1616
attitudeattitude 14.614.6
Ethical conductEthical conduct 6.86.8
Ability to work independentlyAbility to work independently 66
Willingness to seek helpWillingness to seek help 5.25.2
Work habitsWork habits 3.53.5
Larry Gruppen,(2005) Larry Gruppen,(2005) MichiganMichigan
Gauger, P.G., et al., Initial use of a novel instrument to measure professionalism in surgical residents. Am J Surg, 2005. 189(4): p. 479-87. expert group analysis
Van de Camp(2004)Van de Camp(2004)
Medline search using Cohen’s domainsMedline search using Cohen’s domains Plus hand searching the referencesPlus hand searching the references Yielded 173 articlesYielded 173 articles Applying inclusion/exclusion criteria Applying inclusion/exclusion criteria
resulted in 57 articlesresulted in 57 articles From which 90 items were culledFrom which 90 items were culled Sorted into domains by modified Sorted into domains by modified
Delphi techniqueDelphi technique
Van De Camp, K., et al., How to conceptualize professionalism: a qualitative study. Med Teach, 2004. 26(8): p. 696-702. Expert group analysis
3 domains3 domains
Interpersonal professionalismInterpersonal professionalism Meeting demands for adequate contact Meeting demands for adequate contact
with patients and other health with patients and other health professionalsprofessionals
Altruism, respect, integrity, service, honour,…Altruism, respect, integrity, service, honour,…
Public professionalismPublic professionalism Meeting society’s demandsMeeting society’s demands
Accountability, submission to an ethical Accountability, submission to an ethical code/moral commitment,…code/moral commitment,…
Intrapersonal professionalismIntrapersonal professionalism Meeting the demands of the professional Meeting the demands of the professional
bodybody Lifelong learning, maturity, morality,…Lifelong learning, maturity, morality,…
The first stepThe first step Design a Q-sort based on the 90 itemsDesign a Q-sort based on the 90 items Advantages of Q-sortAdvantages of Q-sort
Fun and easy to performFun and easy to perform Computerised analysis packageComputerised analysis package Gives useable and meaningful numbersGives useable and meaningful numbers Data richData rich
DisadvantageDisadvantage Small sample sizeSmall sample size
But trade that off by using it to develop a But trade that off by using it to develop a questionnaire-type instrumentquestionnaire-type instrument
Kerlinger, F.N., Foundations of Behavioural Research. 1986, New York: Holt, Rinehart and Winston Block, Jack (1961/1978): The Q-sort method in personality assessment and psychiatric research. Springfield, IL: Charles C. Thomas. (reprinted in 1978 by Consulting Psychologists Press, Palo Alto, CA).
Why Q-sorts ?Why Q-sorts ?
It forces people to make choicesIt forces people to make choices
And because the data is normally And because the data is normally distributed, comparison between distributed, comparison between subjects is easiersubjects is easier
And factor analysis is possibleAnd factor analysis is possible
Q-sort ordering (80 Q-sort ordering (80 items)items)
43210 5 6 7 8Pile
4 6 10 12 16 12 10 6 4
Agree Neutral Disagree
Cards
Sayle and Taylor ASME Sayle and Taylor ASME 20062006
The five most favoured items The five most favoured items describing professionalism, in describing professionalism, in order, were:order, were: Good clinical Good clinical judgementjudgement, , competence, competence, responsibility, responsibility, protect confidential information, protect confidential information, honestyhonesty
Next stagesNext stages
We need a bigger “n” to have confidence We need a bigger “n” to have confidence over the factor analysisover the factor analysis Chronbach’s alpha is good, but then the number Chronbach’s alpha is good, but then the number
of items is high!of items is high! We need to see if 3We need to see if 3rdrd year students differ year students differ
from 1from 1stst or 5 or 5thth years years We need to see if students differ from We need to see if students differ from
DoctorsDoctors It would be It would be reallyreally interesting to see if Perry’s interesting to see if Perry’s
framework applies framework applies and when they move from A to B – is C ever and when they move from A to B – is C ever
reached?!reached?! Then we need to design an instrument using Then we need to design an instrument using
the critical domains.the critical domains.
Perry Type APerry Type A
1.Basic Duality 1.Basic Duality • Reality with no uncertainty or diversity, belief Reality with no uncertainty or diversity, belief
in absolute answers and authorities, in absolute answers and authorities, obedience instead of responsibility.obedience instead of responsibility.
2.Multiplicity pre-legitimate 2.Multiplicity pre-legitimate • Perception of diversity, but classified as Perception of diversity, but classified as
unwarranted confusion.unwarranted confusion.
3. Multiplicity sub-ordinate 3. Multiplicity sub-ordinate • Diversity and uncertainty accepted, but Diversity and uncertainty accepted, but
classified as temporary in a search for classified as temporary in a search for absolute answers.absolute answers.Clarkeburn, H.M., et al., Measuring Ethical Development in Life Sciences Students: a
study using Perry's developmental model. Studies in Higher Education, 2003. 28(4): p. 443-456.
Perry Type BPerry Type B
4. Multiplicity correlate or First attempt to 4. Multiplicity correlate or First attempt to accommodate diversity and uncertaintyaccommodate diversity and uncertainty relativism subordinate with the expectation to do relativism subordinate with the expectation to do
the right thing either by accepting no answers as the right thing either by accepting no answers as truth-bearing or by subordinating to authority.truth-bearing or by subordinating to authority.
5.Relativism correlate,5.Relativism correlate, Revolution through the inability to assimilate Revolution through the inability to assimilate
uncertainty competing, diffuse and the existence uncertainty competing, diffuse and the existence of absolute answers, everything becomes of absolute answers, everything becomes relativistic.relativistic.
6. Commitment foreseen 6. Commitment foreseen Awareness of the need of orientation in a Awareness of the need of orientation in a
relativistic world, experimentation with different relativistic world, experimentation with different methodsmethods
Perry Type CPerry Type C
7. Initial commitment 7. Initial commitment Initial commitment in one area.Initial commitment in one area.
8. Orientation in implications of commitment 8. Orientation in implications of commitment Experiences with commitment and responsibility, Experiences with commitment and responsibility,
time of personal choices of how to fulfil perceived time of personal choices of how to fulfil perceived responsibility.responsibility.
9. Developing commitment 9. Developing commitment Affirmation of identity among multiple Affirmation of identity among multiple
responsibilities, commitment seen as an ongoing responsibilities, commitment seen as an ongoing activity.activity.
There is an excellent inventory: Yang, F.-Y., Student views concerning evidence and the expert in reasoning a socio-scientific issue and personal epistemology. Educational Studies, 2005. 31(1): p. 65-84.