Education in Internal Medicine
Training and learning professionalism in the medical school curriculum: Current considerations

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Abstract

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned. This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.

Introduction

Maintenance of a doctor's professional status depends on the public's belief and trust that professionals are trustworthy. Such status is not an inherent right, but must be seen as something granted by society. The doctor's professionalism can be threatened by self-interest, peer pressure and commercialism. These can often lead to a conflict between altruism and self- interest [1], potentially leading to for example abuse of power, lack of conscientiousness, failure of self regulation, and inability to adequately address issues important to society [2]. It is now recognized that unprofessional behaviour is something that cannot be managed through disciplinary action and honour codes alone [3]. Instead, pro-active educational programs promoting professionalism are viewed as equally important [4], [5]. Nowadays, professionalism and professional behaviour have become core business for the medical educationalist over the last decade, as evidenced by the enormous rise in the number of articles published on these topics.

Recommendations in the literature concerning measures to address the challenges to professionalism have converged on the establishment of an education community, on a structured curriculum dealing with professionalism, on developing programs for role modelling and mentoring, and on attention to the assessment of professional conduct [6], [7]. The interventions in the field of medical education appear central among these efforts, since it is during medical school that the template for professional conduct in medicine is primarily learned [7], [8]. Apart from implementing a formal teaching curriculum addressing professionalism, it is claimed that in order to sustain a sufficient level of professionalism, medical schools and teaching hospitals should address at least four other broad areas:

(1) improving selection of future doctors, (2) improving the formal instructions of their learners and teachers (students and residents and teaching staff and clinicians), (3) improving the clinical learning environment (workplace) and (4) remediating their own unprofessional practices [9], [10]. The development and maintenance of professional development thereby becomes a continuum spanning the years of medical training, residency and further professional career.

This article attempts to provide a more in-depth discussion of the goals, purposes and current factors influencing teaching and learning professional behaviour in the medical school curriculum and the residency programs.

Section snippets

Why would we teach and assess professional behaviour: who is to benefit?

The reasons for teaching and assessing professional behaviour during medical school are threefold. First, it should instil and nurture the development of personal qualities, values, attitudes and behaviours that are fundamental to the practice of medicine and health care. Second, it should ensure that students understand the importance and relevance of these concepts, demonstrate these qualities at a basic level in their work, and are willing to continue to develop their professional identity

Does identification of professional lapses provide opportunity for remediation?

The underlying assumption of teaching and assessing professional behaviour during medical school is that displayed professional lapses in medical school or during residency training are predictive of unprofessional behaviour after graduation. Identifying these lapses (and attempting to remediate identified unprofessional behaviour) suggests that this provides possibilities for future prevention in some cases. If insufficient attention is paid to development of professionalism, problems arising

Are medical students sufficiently aware of professionalism?

A recent paper reporting what medical students know about professionalism, answered this question basically with: “Not a great deal” [19]. Most medical students have no fundamental understanding of what it means to be a physician and what constitute the core professional values [19]. Medical school applicants frequently have given little thought to what it means to be a physician in terms of professional values [19]. Outside medical school training and at the undergraduate level it seems that

Which dilemmas do students face?

Opinions vary and evolve about how students and professionals should behave1 [21], [22]. Medical students are nonetheless expected to demonstrate the currently professionally appropriate and ethical behaviour. Knowing what constitutes this specific behaviour however, appears to be extremely challenging for students [23] as well as teachers, since context (e.g. time, place and culture) all influence the expected behaviour. Furthermore, evaluation of professionalism, when practiced in a clinical

(Dis)satisfaction with teaching professionalism in the medical school curriculum

In summary, the exposure to ethically problematic behaviours does begin as early as the first years in medical school, is common, and persists over the years in medical school [43]. These data are in support of the view that teaching and assessment of professional behaviour should begin early in the curriculum. Few studies however address the question of satisfaction with contemporary training in professionalism. The available evidence on this topic is discussed in the remaining paragraphs of

Conclusions

Teaching and assessing professionalism serves a purpose for the trainee, for the curriculum, for the institution, and for the public. Teaching professionalism should involve a formal, structured curriculum regarding professionalism. Currently, more than half of students are dissatisfied with current training practices relating to professionalism. Increasing time spent in formal courses in professionalism is associated with increasing satisfaction with training regarding professionalism,

Learning points

  • Professional behaviour cannot be managed through disciplinary action and honour codes alone, pro-active educational programs promoting professionalism are currently viewed as at least equally important.

  • The teaching and assessment of professionalism serves a purpose for the trainee, for the curriculum, for the institution, and for the public.

  • Teaching professionalism should involve a formal, structured curriculum in combination with informal discussions and clinically oriented teaching rounds.

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