|ORIGINAL RESEARCH ARTICLE
|Year : 2014 | Volume
| Issue : 2 | Page : 193-199
Medical students' and postgraduate residents' observations of professionalism
Rae Spiwak1, Melanie Mullins2, Corinne Isaak2, Samia Barakat2, Dan Chateau3, Jitender Sareen Sareen4
1 Community Health Sciences and Psychiatry; Department of Psychiatry, University of Manitoba, Manitoba, Canada
2 Department of Psychiatry, University of Manitoba, Manitoba, Canada
3 Community Health Sciences, University of Manitoba, Manitoba, Canada
4 Professor of Psychiatry, Psychology, and Community Health Sciences, University of Manitoba, Manitoba, Canada
|Date of Web Publication||31-Oct-2014|
Dr. Jitender Sareen Sareen
PZ430 - 771 Bannatyne Ave Winnipeg, MB, R3E 3N4
Source of Support: Preparation of this article was supported by a Social Sciences and Humanities Research Council Doctoral Scholarship (Spiwak), a Canadian Institutes of Health Research (CIHR) New Investigator Award (#152348) (Sareen), and a Manitoba Health Research Council Chair award (Sareen),, Conflict of Interest: None
Background: There is increasing interest in teaching professionalism to medical learners. The purpose of this study was to explore professionalism observed among medical learners and faculty in a Canadian academic institution. Methods: A total of 253 medical learners (30% response rate) completed an online survey measuring medical professionalism. The survey used a validated professionalism scale "Climate of Professionalism", which queries subjects' observations of professional and unprofessional behavior in clinical teaching environments. Results: Overall, 73.3% of medical learners felt prepared in the area of medical professionalism. Differences existed in observed professionalism by level of training. By respondents' reports, both medical students and residents viewed their peer groups as more professional than the other. Both groups also rated faculty as the poorest in terms of observed professional behaviors but the best in observed unprofessional behavior. Discussion: Most learners in this Canadian medical school felt well prepared in the area of professionalism, and each training level viewed their peer group as the most professional. Peer groups may rate themselves more favorably due to increased interaction with their group, and active recall of professional communications. This study found differences in observations of professionalism by training level, therefore provides support for specialized professionalism education tailored to the learners level of medical training.
Keywords: Behavior, education, learner, medical students, medicine, professional, professionalism
|How to cite this article:|
Spiwak R, Mullins M, Isaak C, Barakat S, Chateau D, Sareen JS. Medical students' and postgraduate residents' observations of professionalism. Educ Health 2014;27:193-9
| Background|| |
Medical professionalism is said to be the "keystone of the social contract between medicine and society at large".  Essential to this contract is the public trust in physicians, which is dependent on the integrity of physicians and the medical profession as a whole.  Numerous studies have suggested professionalism is being threatened ,, and that the medical profession is not addressing this issue adequately,  In response, medical schools across Canada , and the USA have developed professionalism plans, protocols and committees. ,,,,,,,,, Central to addressing professionalism are defining what professionalism is , and how best to define good professional behavior.  The features of professionalism most identified in the literature highlight integrity, respect, competence, honesty, trustworthiness and accountability. , Measurement of professionalism is an important part of investigating and teaching medical professionalism.  Specifically, examining the climate of professionalism is needed to understand medical professionalism in learning environments. While various features of professionalism have been identified, the optimal methods of teaching medical professionalism have garnered much discussion. , Some experts maintain professionalism should be taught explicitly during medical training using definitions or list of professional traits, , and then be reinforced through experiential learning.  Experiential learning may involve witnessing poor professional behavior by physicians, medical educators and medical learners, which has been identified as a significant concern in previous studies. ,,,
Studies regarding the teaching of medical professionalism have focused on small non-Canadian samples, leading to poor generalizability in the Canadian context. , Additionally, no studies have compared medical student and resident perspectives on the climate of professionalism across a range of specialties. It is important to compare medical student and resident groups, as they will have different exposures to medical training and different levels of experiential learning. This experience and experiential learning may impact their own behavior, as well as their perception of other medical students, residents and faculty. If differences between medical students and residents are demonstrated, it may suggest the need for different, specifically targeted professionalism curriculum for different learner groups. Likewise, findings also have the potential to be used to evaluate and monitor the effectiveness of professionalism efforts in different clinical teaching environments.
Quaintance et al. developed the "Climate of Professionalism" instrument, which focused on measuring observations of professionalism among 371 American medical learners. The survey asked students to report the extent to which student peers, residents and faculty act professionally in a clinical environment. The instrument used the American Board of Internal Medicine's definition of professionalism to develop its scale items.  The survey contained four sets of items, three of which elicited perceptions about the frequency of student, resident and faculty professional and unprofessional behaviors. The final set of items examined student's perceptions about the frequency in which their instructor taught professionalism. The scale showed acceptable internal consistency and convergent validity. The authors found that preclinical students rated faculty's professionalism higher than did clinical students, and students rated faculty's professionalism teaching higher than the faculty rated themselves. Preclinical students also rated others' professionalism higher than did clinical students. Positive correlations were found between students' perceptions of professionalism behaviors and faculty's professionalism teaching, supporting the authors' hypothesis.
Quaintance's finding of differences between preclinical and clinical learners' observations of professionalism provides support for an examination of medical learner groups individually in order to understand if professionalism observations differ among these populations. The goal of the present study is to investigate the reliability and validity of the Quaintance instrument in our Canadian learner population in order to assess professionalism among medical learners, in the Faculty of Medicine. Specifically, the two main objectives are: (1) To ensure the reliability, validity and differences in professionalism scores among groups of medical learners using the Quaintance et al. professionalism instrument, and (2) to compare average scores of professional behaviors among medical learners and faculty as observed by medical students and residents.
| Methods|| |
Participants and Procedure
Quaintance's instrument  was adapted for this study to query observations of professionalism, learner descriptors and the training environment. All 400 medical students and 435 residents in our medical school were emailed an invitation to participate in the study survey (N = 835). The survey was created using SurveyMonkey software and was fielded in March through May 2009. Faculty members were not included as participants in our survey. The program consists of an undergraduate 4-year medical program and post-graduate residency training. Medical students have all previously completed a 3- or 4-year undergraduate degree. Programs consist of 24 accredited primary specialty programs and 22 accredited sub-specialty programs. All ethical approvals were obtained from The University Research Ethics Board. To maximize response rate, two reminder emails were sent, and individuals who completed the survey were told they would be eligible for a drawing for gift certificates to the University Bookstore.
Descriptors of learners and the training environment
The online survey instrument asked medical learners for perspectives on the climate of medical professionalism. The first section of the survey assessed demographic and general descriptive information, including age (18-25, 26-30, 31-35, 36-40, 41-45, 46-50, 51-55, 56 and older); sex (male, female); current level of medical training (medical student, resident and fellow); year of medical school (Med 1, Med 2, Med 3, Med 4); year of residency (Post-graduate year 1 through 7); area of specialty (surgery, family medicine and related specialties, psychiatry, pediatrics, anesthesia, obstetrics and gynecology, and other [genetics, nuclear, emergency, radiology and other]); location of birth (born in Canada, not born in Canada); and location of training (Province of Manitoba, elsewhere in Canada, United States, outside of United States and Canada). Medical learners were also asked various questions to characterize the teaching and training of professionalism within their curriculum, including their perceived level of professionalism preparedness (satisfactorily/well prepared, not at all prepared/poorly prepared).
Climate of professionalism
Using the "Climate of Professionalism" scale, medical students and residents were asked 11 questions on their observations of selected professional and unprofessional behavior among medical students, residents and faculty [Table 1]. For each question, response options were: (1) Not observed, (2) not sure, (3) rarely, (4) sometimes, (5) often and (6) mostly (most frequently observed). Negatively worded items were reverse coded; hence, high scores reflected positive professional behaviors. Individuals that responded 'not sure' were included in analyses to maximize sample size, and were scored higher than 'not observed' (event was never observed) and lower than 'rarely' (event was observed but occurrence was rare). This scoring was felt to be justified because if a participant was not sure an event occurred, it may be that the event occurred, whereas if a participant says that a behavior was not observed then they feel more certain that, in fact, the event did not occur. Select medical student and resident representatives reviewed the survey questions in the development stage for face and content validity.
Cronbach's alphas were calculated to estimate the internal consistency of the 11 items in our respondents. Cronbach's alphas were poor and ranged from 0.422 to 0.645. Means ranged from 44.6 to 45.7 depending on the group observed, with the highest mean reflecting professional behaviors by faculty. Based on the poor results of the Cronbach's alphas, exploratory factor analysis was conducted to confirm the instrument operated the way intended on our sample. Exploratory factor analysis was also conducted to determine if there were interrelationships among the 11 items in the tool and to reduce the data to common underlying dimensions or factors. Two main constructs were found for each group (data available upon request), and Cronbach's alpha was again conducted on the two separate scores in each group to examine reliability. As these alphas were much improved, further analyses were calculated utilizing these two constructs (unprofessional and professional behaviors for each group - medical students, residents and faculty). New scales were created based on the sum of values on the set of items identified as professional and unprofessional.
Once improved reliability was determined, differences between the mean observed professionalism and unprofessionalism scores were examined for student, resident and faculty groups using, analysis of variance (ANOVA). In addition, mean scores of professionalism observations were compared using independent sample t-tests to determine if there were significant differences between the means of medical students and residents average rating of observed professional behaviors. Effect sizes were calculated to compare medical students' and residents' mean professionalism scores of medical learners. One question regarding unprofessional Internet networking postings was added to the survey based on face validity discussions with a medical student representative. The question asked how often the learner observed the posting of inappropriate content (pictures, comments or materials) on social networking sites such as Facebook or Twitter. The response options were: Mostly, often, sometimes, rarely and not observed. Kruskal-Wallis tests were used to determine whether there were significant differences among scores of observed unprofessional online posting among medical students, residents and faculty. SPSS statistical software was used for all analyses. 
| Results|| |
Out of the total of 835 possible medical learners, 253 subjects completed questionnaire for an overall response rate of 30%.The response rate for medical students was 35%, and for residents, it was 27%.
Descriptors of Students and Training Environment
Fifty-one percent of respondents were male, and 49% were female [Table 2]. Fifty-four percent were medical students and 46% were residents. Percentage breakdown of year of residency, area of specialty and other demographic variables were also calculated [Table 2]. Questions about professionalism preparedness found medical learners were satisfactorily or well prepared in the area of medical professionalism (73.3%), with no significant differences between medical students and residents (P = 0.88).
Climate of Professionalism
[Table 3] shows Cronbach's alpha values as well as mean scores for professionalism and unprofessionalism constructs by group. Means ranged from 20.30 to 26.17 for unprofessional behaviors, and from 19.53 to 24.67 for professional behaviors. Faculty had the lowest observed mean professionalism score (19.53) as compared with medical students and residents (M = 21.00 and M = 24.67). However, faculty reported the fewest observations of unprofessional behavior (M = 26.17), reflected in the overall highest mean. There were significant differences between unprofessional and professional means across students, residents and faculty (P =<0.001; P = 0.001).
|Table 3: Internal consistency and mean differences (ANOVA) among medical learner's observation of professionalism scores (professional and unprofessional scores)|
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Medical students reported that they observed faculty's professionalism behaviors significantly less often (M = 24.10) than did residents (M = 25.44, P = 0.008). Medical students reported that they observed faculty's unprofessionalism behaviors less (M = 22.45) than did residents (M = 19.22, P = <0.001). Also, residents reported that they observed professionalism by residents significantly more often (M = 27.69) than did medical students, (M = 21.97, P = <0.001), and rated unprofessionalism among residents as occurring more often (M = 17.54) than medical students (M = 22.73, P=<0.001). Medical students' (M = 26.81) and resident's (M = 25.49) perceptions of medical students' professionalism did differ (P = 0.018), however, perceptions of unprofessionalism did not (P = 0.52) [Table 4].
|Table 4: Differences between medical students and residents observations (mean scores) of professionalism and unprofessionalism by behavior group|
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Kruskal-Wallis tests were used to examine differences between mean ranks of observed unprofessional online posting scores between medical students and residents, among medical students, residents and faculty. Significant differences were found between medical students and residents for each observed group respectively (medical students, P < 0.001; residents, P < 0.002; faculty, P < 0.001), with the highest mean rank of unprofessionalism given to medical students as observed by residents (152.33). Unprofessional online posting by faculty had the lowest mean rank, as observed by residents (101.75).
| Discussion|| |
In this assessment of professionalism observed by medical learners, we found first that while medical learners were satisfied with the professionalism training received, they nevertheless frequently observed unprofessional behaviors. It could be although medical learners believe they are taught professionalism adequately, they are not putting teachings into practice. While Quaintance et al. found evidence that their tool was reliable and valid, in our sample Cronbach's alpha for medical students approached 0.7, but residents and faculty had lower values, suggesting a possible limitation of this tool in our sample. While this may be the case, the exploratory factor analysis indicated that data were reduced to separate constructs, one reflecting professional behaviors and one reflecting unprofessional behaviors. Once analyses were conducted among each construct, significant differences were found in observed professional and unprofessional behaviors between medical students, residents and faculty. Findings suggest medical students and residents reported observations of professionalism and unprofessionalism are different. These overall observed professionalism scores by group give an overall measurement of the climate of professionalism in our institution. Differences in respondents' reports between these groups suggest that overall, some groups are perceived as being more professional than others. Residents' observed professional behaviors received the highest average score out of all survey respondents, with faculty receiving the lowest score on positive professional observations. It may be that medical learners see residents as behaving in a more professional manner due to their later stages in training. Determining that differences exist between groups has important implications for the development of professionalism curricula targeted at various groups. For example, faculty professionalism may be identified as an area of future study. While differences in respondents reports exist between medical learners and faculty, medical learners perceptions of their own peer group (both medical student and resident) is different and interesting. While medical students received the lowest overall observed professionalism score by all participants, when reflecting on their own perceptions of other medical students, they rated their peer group as more professional than residents. Residents in turn also perceived their peer group to be more professional than medical students. It may be that each peer group rates their observations of professionalism more favorably as they have more interaction with their group and actively recall professional interactions. Each peer group may rate themselves more favorably because they socially identify with their group and therefore maximize positive characteristics and behaviors (or minimize negative ones). When examining observations of unprofessional behaviors, residents ranked their peer group as less unprofessional than medical students. While the comparison of medical students and residents reported unprofessionalism by medical students resulted in a non-significant difference, the average score found residents to be slightly more unprofessional. This trend supports the idea that each learner group finds themselves to be more professional, and less unprofessional than the other. As this conclusion is based on a group's perception of professional behaviors, it is difficult to determine if findings are impacted by a social identity/desirability effect. Regardless, this study found differences in reported observations of professionalism by training level, therefore provides support for specialized professionalism education tailored to the learners level of medical training.
While both medical students and residents reported their peer groups as each more professional than the other, both groups rated faculty as the poorest in terms of observed professional behaviors. This finding suggests experiential learning by medical learners may require further investigation in our sample. Medical students also reported faculty as less unprofessional as compared with residents' rating of faculty. Residents have increased length of time in training, greater exposure with faculty and, as such, greater opportunity to experience unprofessional interactions. While faculty members did have the highest mean rating of observed professionalism overall, when broken into professional and unprofessionalism behaviors, medical learners observed fewer unprofessional behaviors among faculty, instead of a greater frequency of professional behaviors. Unprofessional behaviors may hold greater weight in terms of effect, and instructors need be mindful that one unprofessional act may outweigh many acts of professionalism. This finding needs to be carefully interpreted, as the reliability of faculty professional behaviors in this sample is low (Cronbach's alpha = 0.510). Regardless, observed professional and unprofessional behaviors by faculty is an important area because faculty are role models for medical learners. 
The current study also found that medical learners are observing inappropriate online behavior by fellow medical students. This behavior was also observed in residents, although at lesser occurrence than medical students. Online posting is a current phenomenon, and it is important to address the role of online media and posting practices in the context of medical professionalism. In our study, medical students, residents and faculty online posting behaviors were reported. In contrast to a study by Chretien,  our study found postgraduate residents are commonly observing unprofessional behavior. Previous studies have also shown that medical students and residents have online profiles, which subjectively display unprofessional behavior.  Further study across a broad range of medical learners with more detailed questions related to type of online posting behavior is required to assess this new phenomenon.
The current study was limited by our sample because only medical learners from one medical institution participated. A second limitation is the lower level of reliability for the Climate of Professionalism tool, as compared with Quaintance's study.  While these scores are lower in our sample, this may reflect differences in populations, therefore a different scale to measure observed professionalism in our own environment may be reasonable. The current study was also limited by the lower response rate, although the response rate for this study is well within the bounds of expectation for online data collection.  While limitations exist, the current study expands research in the area of medical professionalism because there is little published research investigating self-rated assessments of professionalism preparedness by medical trainees. Previous studies have focused on one specialty or level of training, not allowing comparisons between groups. Also, unlike previous studies using individual scales to evaluate professionalism, our study used a validated scale that was re-validated for our sample, including other descriptive measures in order to obtain observed professional and unprofessional behaviors from medical learners. Our study also adds further insights into online posting of professional and unprofessional behaviors by medical learners and faculty.
In summary, the current study demonstrates reported professional behaviors from a population spanning all medical specialties, and all levels of training. The heterogeneous study population makes our findings particularly noteworthy. Further research should explore professionalism education needs among medical students and residents, online unprofessional posting, as well as the role of observant learning and faculty professionalism. Future assessments of professionalism can be used to measure the effect of future education or policy initiatives to improve professionalism.
| Acknowledgments|| |
Bruce Martin for suggesting the question regarding online posting of unprofessional content.
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[Table 1], [Table 2], [Table 3], [Table 4]