|Year : 2014 | Volume
| Issue : 2 | Page : 200-204
Attitudes towards professionalism in graduate and non-graduate entrants to medical school
Siún O'Flynn, Stephen Power, Mary Horgan, Colm M. P. O'Tuathaigh
School of Medicine, Brookfield Health Sciences Complex, University College Cork, Cork, Ireland
|Date of Web Publication||31-Oct-2014|
Colm M. P. O'Tuathaigh
School of Medicine, Brookfield Health Sciences Complex, University College Cork, Cork
Source of Support: None, Conflict of Interest: None
Background: The number of places available in Ireland and the United Kingdom (UK) for graduate entry to medical school has increased in the past decade. Research has primarily focused on academic and career outcomes in this cohort, but attitudes towards professionalism in medicine have not been systematically assessed. The purpose of this study was to compare the importance of items related to professional behaviour among graduate entrants and their 'school-leaver' counterparts. Methods: This was a quantitative cross-sectional study, conducted in University College Cork (UCC), Ireland. A validated questionnaire was distributed to undergraduate-entry (UG) and graduate-entry (GE) students with items addressing the following areas: Demographic and academic characteristics and attitudes towards several classes of professional behaviours in medicine. Results: GE students ascribed greater importance, relative to UG students, to various aspects of professionalism across the personal characteristics, interaction with patients and social responsibility categories. Additionally, in UG students, a significant decrease in perceived importance of the following professionalism items was evident across the course of the degree programme: Respect for patients as individuals, treating the underprivileged and reporting dishonesty of others. Among both groups of students, individual mentoring was rated the most important method for teaching professionalism in medicine. Discussion: This study is the first comparison of attitudes to professionalism in UG and GE students. This study highlighted important group differences between GE and UG students in attitudes towards professional behaviours, together with different perspectives regarding how professionalism might be incorporated within the curriculum.
Keywords: Graduate-entry, medicine, professionalism, undergraduate-entry
|How to cite this article:|
O'Flynn S, Power S, Horgan M, O'Tuathaigh CM. Attitudes towards professionalism in graduate and non-graduate entrants to medical school. Educ Health 2014;27:200-4
| Background|| |
The introduction of graduate-entry (GE) programmes in Australia (1996), the United Kingdom (UK) (2000) and Ireland (2006) was prompted by pragmatic concerns related to the shortage of medical graduates entering the workforce, as well as a desire to broaden the socio-demographic and academic basis for undergraduate (UG) admission. ,,,, In an international context, North American systems of medical education have traditionally involved students entering medical school following completion of a previous university degree. Studies to-date have demonstrated a high completion rate for GE students in medical school, proving that this cohort can perform as well, or even better, than school-leavers (or those who enter medical school immediately following completion of secondary education) in their academic performance and clinical skills assessments. ,, Distinct cognitive and socio-emotional profiles have also been described for graduate entrants relative to UG entry counterparts. Graduate entrants have been rated as significantly more conscientious, communitarian in moral orientation, co-operative, and less anxious than their UG counterparts. ,
While it has been suggested that motivational variables in graduate entrants may influence academic performance, career choice, as well as likelihood of completing the medical course,  it is unclear whether these differences extend to professional behaviours and general attitudes towards professionalism. While the development of professional behaviours among physicians has traditionally relied on implicit learning from role models, recent decades have seen academic bodies internationally, including the Association of American Medical Colleges (AAMC) and the UK General Medical Council (GMC), define professionalism as a core competency for medical students and resident trainees. , Despite the increased emphasis on the role of professionalism, there is ongoing debate about how to define and measure the concept, as well as lack of clarity concerning the determinants of attitudes to professional behaviours.  In particular, the ongoing question of whether GE courses produces good (or even better) doctors must be examined in the context of their attitudes towards professionalism, as there is increasing evidence that doctors disciplined by regulatory bodies during their medical career demonstrate unprofessional behaviour and attitudes during their UG training. ,
The present study, employing a quantitative survey-based approach, examined potential differences in the perceived importance of certain aspects of professional behaviour between GE and UG medical students. The null hypothesis was that attitudes towards professionalism in medicine would not be perceived differently in these two student populations.
| Methods|| |
This study was a quantitative cross-sectional study conducted at the School of Medicine, University College Cork (UCC), Ireland. Study participants were medical UG students enrolled in either direct-entry UG programme [years 1, 2, 4, 5] or the graduate entry medicine programme [GE; years 1-4] during the academic year 2011-2012. A convenience sampling method was employed. The study was approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals.
Attitudes towards professionalism were measured using a questionnaire developed and described previously.  This survey tool grouped professionalism under the following four categories [Table 1]: Personal characteristics; Interaction with patients; Social responsibility; Interactions with the health care team. Additionally, several items were included to examine Strategies for developing professionalism. Participants were asked to rate the items listed above on an ascending 5-point Likert scale with rating options: Not at all important, somewhat important, neutral, important and very important. For each category, participants were also asked to list the two most important items. Survey tool items were initially constructed based on a review of the literature concerning the development of professionalism in medical students; internal consistency was shown to be high for three of the four professionalism categories (personal characteristics, interactions with patients, interactions with the healthcare team).  The internal consistency reported for items related to social responsibility was lower, but they were included in the present study for comparison purposes. Questions regarding demographics and educational background were also added. Procedures: For each group and year of study sampled, paper questionnaires were distributed to students in a lecture theatre at the end of a lecture or tutorial during 23-25 th January 2012. All students were provided with instructions for completion of the questionnaire, as well as notification that: (a) They were free to withdraw consent to participation at any point; (b) That all responses would remain anonymous and confidential; and (c) That questionnaires should be completed without sharing of information with fellow students. The completed questionnaires were collected after a 15- to 20-min period.
|Table 1: Mean importance ratings (on a 1 - 5 scale, where 1=not at all important, and 5=very important; see Instruments) for four categories of professional behaviours, as well as strategies for developing professionalism, in GE vs. UG students|
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Mann-Whitney U and Kruskal-Wallis analysis of variance (ANOVA) tests were used to compare ratings of perceived importance of professional behaviours between groups. Statistical analyses were carried out using PASW Statistics 18 [IBM, New York, NY, USA].
| Results|| |
Questionnaires measuring attitudes towards professional behaviours from 72 GE and 115 UG medical students were analysed, with the following response rates: GE students - 53.8% (72/132); UG students − 26% (115/445). In descending order, the majority of GE respondents had completed their first degree in the areas of Biomedical Sciences (46%), Engineering and Physical Sciences (22%), Arts, Business and Law (18%) and Health Sciences (14%).
[Table 1] summarises importance ratings for various professionalism-related categories and items across both the UG and GE student groups. Overall, relative to their UG colleagues, GE students provided higher importance ratings for each of the categories, aside for items belonging to strategies for developing professionalism [Table 1].
In terms of the personal characteristics category, both UG and GE students rated all items either important or very important (i.e. mean ratings between 4 and 5). GE students ranked punctuality (Mann-Whitney U = 3318.5, z = 2.51, P = 0.01) and knowledge of limits (Mann-Whitney U = 3367, z = 2.32, P = 0.02) higher than UG students. For both groups, the two most highly ranked items were reliability in the completion of patient care tasks (GE: 48%; UG: 41%) and internal motivation (GE: 40%; UG: 41%).For each of the items, a year-by-year comparison of importance ratings across both curricula revealed no significant differences.
For the interaction with patients category, GE students rated maintaining patient confidentiality (Mann-Whitney U = 3529.5, z = 2.10, P = 0.04) as significantly more important, and there was a non-significant trend towards increased ratings for respect for patients' involvement in decisions (Mann-Whitney U = 3528, z = 1.86, P = 0.06) in GE versus UG students. For both groups, the two most highly ranked items were respect for patients as individuals (GE: 65.3%; UG: 59.5%) and respect for patient involvement in decision-making (GE: 29%; UG: 30.2%). A comparison across years for each curriculum revealed a significant decrease in importance of respect for patients across years 1-5 in UG students (X 2 =7.61, P < 0.05); post-hoc comparisons indicate that the significant differences lie between years 1 and 2 and years 4 and 5 (all P < 0.05).
For social responsibility, there were no significant differences between both student groups with respect to importance ratings. For both groups, the two most highly ranked items were improving access to health care (GE: 65.3%; UG: 59.5%) and treating the underprivileged (GE: 13.9%; UG: 22.4%). Among UG students, there was a significant decrease in importance of treating the underprivileged across years 1-5 (X 2 =7.97, P < 0.05), with post-hoc analyses revealing a significant difference between year 1 and each of years 2-5 (all P < 0.05). Perceived importance ratings for promoting just distribution of resources increased in GE students between years 1 and 4 (X 2 =9.36, P < 0.05).
For interaction with healthcare team category items, no significant differences in importance ratings were found between UG and GE students. However, ratings of importance for reporting dishonesty of others selectively decreased in UG students between years 1 and 5 (X 2 =7.71, P < 0.05). With respect to strategies to improve professionalism, the highest ranked strategy across both programmes was individual mentoring, followed by inclusion of formal evaluation of professionalism, with no difference in item importance ratings between the programmes.
| Discussion|| |
GE students ascribed greater importance, relative to UG students, to various aspects of professionalism across the personal characteristics, interaction with patients and social responsibility categories. Additionally, in UG students, a significant decrease in perceived importance of the following professionalism items was evident across the course of the degree programme: Respect for patients as individuals, treating the underprivileged and reporting dishonesty of others.
While both UG and GE students generally rated each of the four professionalism category items as either "important" or "very important", GE student ratings were higher on average, and they assigned significantly greater importance to punctuality, appearance, as well as patient confidentiality. For the first two items, this may reflect increased likelihood of previous exposure to work environments, and a more keen approach to what may constitute general professional work practices. In relation to patient confidentiality, this difference may reflect greater maturity in terms of ethical orientation and intellectual/emotional maturity. ,
An ancillary issue arising from this study concerned exploration of whether students' attitudes to professionalism change during their training. It is notable that UG students attributed less importance to specific patient-related and socially conscious professional behaviours at the end of their course relative to UG students starting their degree. It should be pointed out that the mean importance rating for each of these professional behaviours was greater than 4, that is "important" for students polled at the beginning or end of the programme. These results are in agreement with previous reports of a greater proportion of first-year medical students clearly identifying inappropriate behaviour when compared with final-year students.  It may be speculated that the decrease in perceived importance of various professional behaviours in UG across years 1-5 of the degree programme may represent the influence of the "hidden curriculum", defined as a set of values modelled by senior physicians within a clinical setting, and which may contradict those of the formal curriculum.  There is evidence to support the lack of agreement between the professional values taught in formal curricular activities and those expressed informally between mentor and mentee in clinical environments. ,
In a study by Morreale et al.,  when medical UGs were asked how they felt professionalism is best taught, role models and learning through experience were identified as being the most useful sources. Lectures and online teaching were not felt by many to be valuable resources, highlighting current differences between how professionalism is taught and how students feel they learn best. The present results support this perspective.
A recent qualitative analysis of narratives recorded by Israeli students on a medical clerkship revealed that student learning about professionalism was highly associated with experience of communicating and working within healthcare teams.  Alongside the current findings, these data contribute to the ongoing debate regarding the timing of formal teaching of professionalism as well as its integration into current medical curricula.  In terms of curricular strategies to promote development of professionalism, they highlight the importance of the clinical environment, where informal interaction between mentor and mentee is most evident, as well as provision of opportunities to participate in healthcare teams.
With respect to study limitations, the response rate to this professionalism survey was lower among UG relative to GE students, with many of the students across both groups absent due to alternative academic commitments (i.e. both Cork-based and overseas clinical rotations) during the sampling period. Additionally, the potential impact of previous background degree area on GE responding in this study was not measurable due to the limited sample size. Although anonymity was assured, and despite the request that survey responses were not to be discussed with fellow students, the possibility exists that these factors may have exerted a residual influence, promoting a pattern of responding biased towards the upper end of the scale (i.e. towards high importance ratings). Finally, the cross-sectional design used in the present study limits the capacity to infer changes in attitudes to professionalism across the duration of the degree programme; future studies might address this question better by employing a cohort study design.
Research comparing graduates with different pre-medical school backgrounds is essential, given the increased number of students from both programmes who are now entering the workforce, and considering the number of medical schools considering changes to admission policies. This study highlighted important group differences between GE and UG students, at both the start and end of their respective degree programmes, in attitudes towards professional behaviours, together with different perspectives regarding how professionalism might be incorporated within the curriculum.
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