Students have great insights on their perceived needs with regard to their education.
Most of the students reported that our current professionalism curriculum was effective. They prefer real cases discussed by clinical faculty to lecture based learning. Students want professionalism to have a prominent place at their school but not necessarily in their didactic curriculum. When compared to other areas of the curriculum, our students consider professionalism content as excessive and not fully effective (Table
). Close to one third of the students found that the professionalism presentations and orientation week were ineffective. Formal activities were also seen as ineffective by close to one forth. This is also the perception of students across the country regarding their own programs
] as the AAMC Canadian Medical School Graduation Questionnaire which is conducted across Canada at completion of medical school, found that 24% of all students (and 30% at the University of Ottawa) found the curriculum excessive. Leo and Eagen have studied why students “cringe” and feel patronized when the topic of professionalism is discussed in their curriculum
]. They emphasize that to foster credibility, programs must promote and adhere to the same principles at all levels of training and position.
The University of Chicago Pritzker School of Medicine developed an institution-wide Roadmap to Professionalism, a program to increase awareness of medical professionalism
]. It included the student survey using the Pritzker list of behaviors, which we used with permission. Over time, behaviors that the students previously considered unprofessional, became increasingly more acceptable as students progressed in their training, indicating some erosion of values. Our students also did not consider their own behaviors from the Pritzker list (Table
), such as emailing during class or leaving class early, as unprofessional. This may be possibly related to student comfort with multi-tasking and self-directed learning, but it also suggests that our current generation of learners may have a different perception of professionalism as it relates to specific behaviors
]. This raises the importance for teachers to clearly identify and make explicit the expectations of medical students as they interact in classroom and clinical settings.
In addition, students in our study identified that evaluation of professionalism was often seen as ineffective. Evaluation of professionalism is an acknowledged ‘Achilles heel’ in the efforts to develop a complete professionalism program. Ginsburg and collaborators have shown that behavior is contextual: that the student’s and the evaluator’s perception often determine whether the unprofessional behavior is actually recorded or reported
]. In a study with faculty responding to five videotaped scenarios in which students were placed in professionally challenging situations, there was a general lack of agreement of how students should act
]. There was a lack of a shared standard for professional behaviour in students, and the authors emphasize how context drives behaviour, and needs to be considered in professionally challenging situations, beyond the student’s apparent behaviour.
According to our students, role modeling continues to be the single most important component of the medical school experience as it relates to professionalism and the development of professional identity. In general, the attributes not highly emphasized by faculty are not highly valued by students (Tables
b). Recent publications speak to the fact that empathy can be taught and role modeled
] and yet this was one of the attributes least emphasized by faculty in our study, and the least highly ranked by the students. Our findings are similar to those of Brainard and Brislen who collected students’ experiences from five American medical schools, and found several barriers to medical professionalism education which included unprofessional conduct by medical educators, substandard professional behavior accepted in exchange for efficiency, and institutions lacking whistleblower protection
]. Kenny et al. have stated that role modeling is an untapped educational resource that needs to be emphasized in faculty development initiatives
Students from our school and all schools across the country continue to experience unprofessional behaviors in pre-clinical and clinical environments
]. This is part of the “hidden curriculum” which in defined as a set of values which contradicts those of the formal curriculum
]. Work from Hafferty suggests that the learning environment needs to reflect the professionalism curriculum, so that students can benefit from consistent education, clear expectations and assessment. The issue of the learning environment is one that must be addressed by medical schools, their affiliated institutions and all their distributed settings
The McGill physicianship program initiated by Cruess and Cruess has put the principles that the cognitive base of professionalism must be taught explicitly
], with a special emphasis on the social contract
], into action
], and is accompanied by faculty development
]. The importance of faculty development cannot be overemphasized in this context.
There are several possible routes to improving the ‘culture of professionalism’ within a faculty or institution. A survey of Canadian faculties undertaken by the authors (AB, WH)in the same year indicated that most medical schools had a professionalism curriculum in place for the ‘pre clerkship’ phase, but lacked a formal program in the clerkship years
]. This may be also reflected in our study where we found students in early clinical years giving a lower rating to our program effectiveness (Table
). It is important that schools provide a longitudinal professionalism curriculum throughout the entire MD Program supported by positive role models and school administrative activities. Students want to be inspired by guest lecturers and to celebrate exemplary professionalism by creating awards for both students and faculty. They also expect to have professionalism lapses by students, residents and faculty managed appropriately. Our students identified several improvements to strengthen professionalism programs, including guest lecturers, awards to staff, and medical program professionalism web pages (Table
Based on this extensive review and students’ perspectives, we have developed an ‘Action Plan on Professionalism” which is in process of being implemented at our school (Table
). Our program is now being modified and expanded to include more explicit teaching on professionalism in the preclerkship phase, and plans for a full four-year program accompanied by trained faculty are well underway. A Reaffirmation Ceremony with presentations from residents and faculty and a reading of an oath is held at the start of clinical clerkship, to remind the students of the attributes and responsibilities as they enter the clinical phase of their learning. The orientation week now also includes interprofessional sessions, that allow early exposure to the field of collaborative practice.
Action plan on professionalism: strategies for developing student professional identity
Recent work on reflection includes studies that show that student narratives can influence professional development, as debriefing allows individuals to explain, analyze and synthesize information and emotional states, and to improve performance in similar situations in the future
]. Student narratives can also help understand the informal and hidden curriculum, and assist students in developing their professional identity
An electronic portfolio on our core competencies program has been implemented over the four years, to facilitate student reflection on all the CanMEDS competencies, including professionalism
]. This is supported by coaches, many of whom are primary care physicians, and who participate in an ongoing Faculty Development program. This has become a great venue for our students to debrief, in a supportive and safe environment, on difficult experiences in clerkship, some of which relate to lapses of professionalism. In their work Hilton and Slotnik
] use the Greek term “phronesis”, practical wisdom that is developed by experience and reflection on the experience. It is with practice and time that students develop their professional aptitude along with skills and knowledge, a period the authors call proto-professionalism. The portfolio program can foster this process.
The limitations of this study include the fact that the survey involved only one school and may not be generalizable. We did however have information from other sources such as the Canadian Graduation Questionnaire indicating that many issues regarding professionalism are similar across the country
]. The response rate to our survey was lower in the clerkship years, with 14% in year 3 and 34% in year 4, as many were immersed in local and remote clinical placements. Unfortunately despite frequent email reminders, and the online design, the University of Ottawa clerkship students are often out of province or the country, thus less “captive” and less available to contact. This is a loss of potentially valuable information from students who could have helped to inform on many areas, particularly regarding the learning environment in clerkship. The survey was conducted in 2006 and since then many of the schools have implemented new initiatives for the professionalism curriculum, so it is possible that some of the challenges exposed by this study have been addressed.