Journal of the College of Physicians and Surgeons Pakistan
ISSN: 1022-386X (PRINT)
ISSN: 1681-7168 (ONLINE)
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doi: 10.29271/jcpsp.2022.03.275Professionalism is a broad term that encompasses the skills and attitudes demonstrated by personnel who are specialised in their respective fields. It comprises of not only the talent demanded by the field, but also the other virtues that bring out the true essence of a skillful and ethically sound human being. Like everywhere else, professionalism is the buzz word in medical education. Medical professionalism is a set of values, behaviours, and relationships that underpins the trust the public has in doctors.1 It is the need of the day to implement proper academic strategies to discover the spirit of professionalism in medical students through their undergraduate and postgraduate courses. Professionals deal with the needs that are valued by the community they serve.2 It is a general observation that a less knowledgeable yet professional clinician is applauded more than a more knowledgeable but less professional one.
One issue related to professionalism is the modality of teaching professionalism to medical students. Professionalism is acquired more passively than actively. However, if some part of the curriculum is dedicated to teaching professionalism formally, it will have a positive effect on inculcating professionalism in future doctors.
Medical students begin attending hospital wards in their 3rd year of medical school. Certain facets that are more stressed upon becoming their instincts. Therefore, teaching different aspects of professionalism to these students through the next three years in accordance with the Miller’s Pyramid can foster the true spirit of professionalism in them.
The ancient healer is the modern professional;2 combining the art of healing inherited from the ancient civilisation and the competence and needs of the modern era.2 The practice of medicine is no longer similar to the ancient practices, where the healer had the full authority of decision-making on behalf of the patient. Whatever the healer deemed appropriate, was seconded by the patient and his/her near ones. This is not the case with the modern era of medicine. The clinician needs to give full autonomy to the patient and must be aware of his own limitations and boundaries set by current medical practices in relevance to the society.3,4
The concept of professionalism is quite vague in the minds of medical students. This needs to be clarified by the early inclusion of professionalism in the curriculum. In a case-control study, it was concluded that students who demonstrated unprofessional attitudes in medical schools were more likely to face disciplinary action by regulatory organisations.5 Similarly, students who demonstrate unprofessional attitudes at undergraduate level are more likely to continue the same irresponsible attitudes as clinicians. This can lead to unsatisfied patients and colleagues, ultimately causing a threat to the smooth running of the institution.5
In light of the importance given to professionalism and the interconnecting term of medical ethics in the current era, it is deemed necessary to improve the selection process of undergraduate medical students by allocating a score to demonstration of professionalism, by formally teaching professionalism in medical schools and by discouraging unprofessional teaching and learning environments. The inclusion of professionalism in the recruitment process of medical students is a tricky business and needs medical educationists and experts who themselves are able to assess a medical student’s professionalism at the time of interview.
It would be difficult to clearly discuss how to teach professionalism at medical schools because there are not many schools that are formally teaching it. The history of formal teaching of professionalism is relatively short. 6
Professionalism can be taught by inculcating some important points in teaching and learning environment, such as highlighting the expectations, regular assessments, remediating unsuitable actions, avoiding inapt behaviours, and applying cultural changes.7
Both learners and teachers should receive a list of expected behaviours for which they will be held accountable with explanation of the consequences of acting inappropriately. Professionalism is a broad term that encompasses the attributes of altruism, accountability, excellence, duty, honor/integrity, respect, patient safety, maintaining good medical practice, teaching and training, communication skills, team work, self-management, probity and health.8,9
First and foremost of all, teaching staff needs proper training in conflict management, feedback, supervisory skills and assessment to be able to teach professionalism. The cognitive component can be taught through courses in the history of medicine emphasising the evolution of professionalism over time. Definitions and framework for professionalism can be taught through lectures in medical schools and also at demonstration rooms in hospitals. Other forms of teaching such as small group teaching sessions may be used to explore personal interpretations and biases, whereas, problem-based learning (PBL) or collaborative learning formats also prove helpful to the students.10 A sample PBL scenario demanding for knowledge and awareness about professionalism in the clinical context would be like, medical students can be asked to evaluate the scenario in terms of professionalism on behalf of the attending consultant, enumerate the pitfalls in the consultation, and design an ideal consultation demonstrating professionalism on behalf of the consultant taking the above scenario as an example. Students will then engage in self-study and group/peer study and try to reach a solution to the above problem.
Professionalism can best be taught at the bedside, whereby the whole interaction between a healthcare professional and the patient deems high quality professionalism. The medical students have an excellent opportunity to learn different aspects of professionalism here. These include empathy, integrity, responsibility and recognition of limitations; which can be learnt both passively and taught by the facilitator, too.
Team-based learning (TBL) can also prove helpful in teaching the theoretical/cognitive perspective of professionalism to students. This will comprise of pre-ward self-study, individual on-ward assessments, team on-ward discussion and assessment and then application exercises.11 A certain concept pertinent to professionalism can be taken; for example, accountability and the students can be given handouts and material to read about accountability out of ward. Their knowledge about the topic is then checked individually and as a team inside the ward or in a demonstration room.
These techniques might be augmented further by creating opportunities to participate in community service activities/community based teaching in which professional responsibilities are highlighted.12
While teaching professionalism, stress needs to be asserted not only on the cognitive domain but also on other aspects related closely to professionalism, but not covered by cognition alone. These include communication skills, collaborative skills and skills needed for awareness of duty and limitations. These can very well be groomed by continuous reflective practices.13 Roleplay and simulation can be proved very helpful in teaching the practical perspective of professionalism to undergraduate students. Seniors and consultants act as role models for students; therefore, rather than video clips, vignettes, narratives, and scenarios. What they see in real life and what they passively learn from their seniors will have a greater impact on the practical demonstration of professionalism by these students in future. The position of negative role models also needs to be highlighted so that students do not follow the footsteps of those role models who might be excelling clinically but not professionally.
Taking ‘patient safety’ as an example, we will be discussing how to practically teach this aspect of professionalism to undergraduate students. The first obligation of clinical practice upon a doctor is to ensure that there is no harm at first. Patient safety encompasses many important components related directly or indirectly to patient care. These include state policy, diagnosis, medication, surgery, infection and injury.14
The state policy can affect patient management; and hence safety. A patient who is dependent on medicines received through the Baitul Maal might have to wait for a couple of months till the medicines are made available. This can hamper the management of such patients such as patients with refractory idiopathic thrombocytopenic purpura (ITP) awaiting eltrombopag or viral hepatitis patients waiting for anti-viral therapy. These are some difficult situations related to patient safety; and hence, professionalism that can be directly observed by students on patient encounters in hospital outpatients departments (OPDs).
Professionalism also comes into play while making a correct diagnosis. If the required skills and knowledge needed to make a correct diagnosis are lacking, this can be detrimental to the patient and is a sign of poor professional approach.
Medication is the third component of patient safety. Prescription of inappropriate medication or inadequate dosage to patients comes under gross negligence and is an obstacle to patient safety. This skill is also learned in the OPDs and on ward rounds.
The fourth component of patient safety is surgery. It is associated with multiple risks to the patient in the form of trauma, hemorrhage, infections, etc. Apart from that, informed consent for the procedure, knowledge of site for surgery especially left/right, appropriate covering and draping of patient and safe transfer from operation theater to recovery room and then to ward are also included in patient safety; and demand high level of professionalism from the healthcare professionals. The undergraduate medical students can have good exposure to this aspect of patient safety during their surgery, orthopedics, otorhinolaryngology, obstetrics and gynecology, and ophthalmology rotations.
Infections are a common sight in the hospital setting. These are seen in patients presenting to all specialties. The medical students will see many such patients during their clinical rotations. Microbiologists, pharmacists, and healthcare professionals need to address these.14 Use of personal protective equipment and acquaintance with sterilisation and disinfection techniques can reduce the spread of infections in the community.
Injuries are the final component of patient safety. These include self-inflicted injuries as well as injuries incurred in the clinical setting. Any type of instrumentation can lead to injury, be that a minor procedure like naso-gastric intubation, Foley’s catheterisation or a major surgical procedure.
Teaching the topic of patient safety covers all three learning domains. The cognitive domain can be covered in the form of lectures in the demonstration room. The meaning of patient safety and its components can be taught to small groups of students through lectures. Sterilisation and disinfection techniques can be taught in the skills laboratory to a small group of students through the whole-part-whole technique. This is followed by direct practice by students to ensure giving feedback during the course of practice. The affective domain pertaining to patient safety can also be covered in a small group. Medical students can learn how to take informed consent before a procedure such as lumbar puncture by direct observation at the bedside or through video clips and simulations.
The different aspects of professionalism can be assessed in the form of objective structured clinical examinations (OSCEs), but since the purpose of the current manuscript is to elaborate the teaching strategies for professionalism, a discussion of assessment of professionalism would fall beyond the scope of this editorial.
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