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 Table of Contents  
BRIEF COMMUNICATION
Year : 2020  |  Volume : 33  |  Issue : 1  |  Page : 13-19

Assessing perceptions of professionalism in medical learners by the level of training and sex


1 Department of Community Health Sciences, Psychology, and Community Health Sciences, University of Manitoba, Winnipeg, Canada
2 Department of Psychiatry, Psychology, and Community Health Sciences, University of Manitoba, Winnipeg, Canada

Date of Submission26-Nov-2015
Date of Decision30-Jun-2017
Date of Acceptance16-May-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Rae Spiwak
PZ432b – 771 Bannatyne Ave Winnipeg, MB R3E 3N4
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_316_15

  Abstract 


Background: Canadian medical student and residents' severity ratings of professionalism vignettes were examined to identify the differences in ratings by the level of training and by sex. Methods: Eight hundred and thirty-five medical learners (400 medical students and 435 residents) were invited to participate in an online survey measuring medical professionalism. The survey was composed of questions about descriptive information and professionalism vignettes. The tool consists of 16 vignettes examining respondent's ability to recognize the professional and unprofessional behaviors. For each vignette, participants were asked to rate the severity of the infraction as “not a problem” to “severe.” Wilcoxon rank sum tests and Fischer's Chi-square tests were used to examine the differences in perceptions of professionalism by the level of training and sex, and logistic regression models were created with the level of training and sex to examine their association with binary vignette responses (not a severe infraction and severe infraction); controlling for the effect of the other variable. Results: Overall response rate for the completed survey was 30% (n = 253). Significant differences between males and females were found for lapse in excellence (P ≤ 0.039), inappropriate dress (P ≤ 0.003), lack of altruism (P ≤ 0.033), disrespect (P ≤ 0.013), shirking duty (P ≤ 0.028), and abuse of power (P ≤ 0.006). Females rated all six vignettes as more severe as compared to males. Shirking duty (P ≤ 0.002) was found to have the differences between learner responses. Regressions found sex to be associated with severity of professionalism infractions on seven vignettes. Discussion: Future work is needed in the area of professionalism and sex to understand why female and male learners may perceive professionalism differently.

Keywords: Perception, professionalism, sex, training


How to cite this article:
Spiwak R, Mullins M, Isaak C, Barakat S, Chateau D, Sareen J. Assessing perceptions of professionalism in medical learners by the level of training and sex. Educ Health 2020;33:13-9

How to cite this URL:
Spiwak R, Mullins M, Isaak C, Barakat S, Chateau D, Sareen J. Assessing perceptions of professionalism in medical learners by the level of training and sex. Educ Health [serial online] 2020 [cited 2020 Nov 26];33:13-9. Available from: https://www.educationforhealth.net/text.asp?2020/33/1/13/293335




  Background Top


Debate exists on how to best define and identify professional behavior in the medicine.[1] Many factors impact one's definition or interpretation of medical professionalism, and some research supports sex and level of training as influential factors. Research suggests female learners may be more likely to perceive behaviors as unprofessional.[1] A Canadian study found as medical learners progressed through training, attitude scores toward social issues declined, possibly due to the loss of idealism and impact of the unintended curriculum.[2] Kulac et al. also found the differences in perceptions of unprofessionalism among preclinical and clinical medical students.[3]

Further work is needed in measuring and identifying the perceptions of medical professionalism.[4] Borrero et al. have developed an instrument using an American sample to explore such perceptions.[4] The questionnaire is composed of vignettes depicting unprofessional behaviors and was generated from a focus-group discussion of medicine trainees. This instrument may help to determine if perceptions of professionalism exist among medical trainees across the levels of training. While Borerro et al. did not examine respondent sex, this inclusion may help explain the differences in perceptions of professionalism.[4] While medical professionalism has been examined in the literature, the majority of studies are not generalizable to the Canadian medical community. The goal of this study was to investigate and compare the average scores of Canadian medical student and residents' severity ratings of professionalism vignettes using the Borrero instrument.[4] We examined the potential differences in ratings of professionalism severity among medical learners by the level of training and sex.


  Methods Top


Participants and procedure

An online survey containing professionalism vignettes[4] and experiences of professionalism behaviors[5] were administered to medical program trainees (n = 835) using SurveyMonkey software (SurveyMonkey Inc, San Mateo, California, USA, www.surveymonkey.com). Experiences of professionalism behaviors in this sample have been published elsewhere.[5] All medical students (n = 400) and residents (n = 435) in our medical program were e-mailed an invitation to participate in the study. The medical program at our institution consists of an undergraduate 4-year medical program and postgraduate residency training, and all medical students previously completed a 3–4 year undergraduate degree. The program is accredited by the College of Family Physicians of Canada and consists of 24 primary specialty programs and 22 sub-specialty programs accredited by the Royal College of Physicians and Surgeons of Canada. Ethical approvals were obtained from the University Research Ethics Board. To maximize response rate, two reminder e-mails were sent. Individuals who participated were eligible for a draw for gift certificates at the University bookstore.

Measures

The survey consisted of questions about descriptive information and professionalism vignettes. Medical learners were asked for descriptive information, including age (18–25, 26–30, 31–35, 36–40, 41–45, 46–50, 51–55, 56 and older), sex (male and female), and current level of medical training (medical student and resident/fellow). Respondents' ability to recognize professional behaviors was examined using 16 vignettes. Participants were asked to rate the severity of the infraction as “not a problem,” “minor,” “moderate,” or “severe.”

Analysis

Basic descriptive statistics were calculated. Mean vignette scores were compared for medical students/residents using Wilcoxon rank-sum tests. The distributions of grouped severity ratings (not a problem/minor and moderate/severe) of male and female learners were compared for each vignette to determine the differences in the broader ratings of severity using the two-sided Fisher's exact tests or Chi-square tests of proportions. If significant associations were found for the level of training or sex, logistic regression models were created with both variables to examine their association with binary vignette responses (not a severe infraction/severe infraction); controlling for the effect of the other variable.


  Results Top


Overall response rate for the completed survey was 30% (n = 253). Fifty-one percent of respondents were male, and 49% were female. Fifty-four percent of respondents were medical students and 46% of respondents were residents. The majority of participants were 18–30 years old (73.1%). Findings show variable degrees of severity linked with particular behaviors. The results from the Wilcoxon rank-sum tests indicate the differences between medical students and residents on 4 out of 16 vignettes, including misrepresentation (P = 0.001), dishonesty (P = 0.001), shirking duty, (P = 0.001), and lack of integrity (P = 0.001) [Table 1]. Residents identified vignettes targeting misrepresentation and dishonesty as more severe infractions than medical students. Conversely, medical students found vignettes targeting shirking duty and lack of integrity as more severe infractions.
Table 1: Medical learners' responses to unprofessional behavior vignettes (Wilcoxon rank sum tests)

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A complete breakdown of vignette ratings by the level of training and results from Chi-square tests are presented [Table 2]. One vignette targeting shirking duty (P ≤ 0.002) showed the differences between learner responses. Differences between male and female medical learners were found for six vignettes targeting lapse in excellence (P ≤ 0.039), inappropriate dress (P ≤ 0.003), lack of altruism (P ≤ 0.033), disrespect (P ≤ 0.013), shirking duty (P ≤ 0.028), and abuse of power (P ≤ 0.006). Females rated all six vignettes as more severe compared to males.
Table 2: Vignettes

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The results from the regression analysis showed sex to be significantly associated with severity of professionalism infractions on vignettes targeting misrepresentation, lapse in excellence, inappropriate dress, lack of altruism, disrespect, shirking duty, and abuse of power [Table 3]. A relationship was found between the level of training and severity of professionalism infractions for shirking duty.
Table 3: Results of logistic regression analyses

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  Discussion Top


The findings suggest that identifying unprofessional behavior is not a simple process. Respondents' perspectives were similar for the majority of vignettes; however, there was significant disagreement on several. Overall, female sex appeared to impact the rating of infraction more than level of training. When level of training was examined independent of sex, four vignettes showed the differences in the average scores of professionalism by medical students and residents. More residents found misrepresentation and dishonesty were severe offences, as compared to medical students. Conversely, more medical students found shirking duty and lack of integrity were more severe offences as compared to residents. Borrero et al.[4] found differences in their sample on abuse of power and lack of conscientiousness. Our study also demonstrates the wide distribution of responses across professionalism scale items. However, once severity ratings were grouped, only shirking duty was found to demonstrate a difference among medical learners.

While misrepresentation, dishonesty, shirking duty, and lack of integrity may be difficult to assess regardless of the level of training, upon review it appears social desirability and group membership may play a part. Specifically, for vignettes where resident behavior was in question, residents were less likely to label the offence as severe, as compared to medical students. Similarly, when medical student behavior was in question, medical students were less likely to label the offence as severe as compared to residents. While severity of these behaviors may be difficult to classify, it may be that this trend represents loyalty to one's own study cohort. Stern discusses the importance of context when assessing professionalism and argues social desirability heavily influences professional behavior.[6] Spiwak et al. also found social desirability may have been involved in the rating of observed professionalism behaviors, with residents rating their peers more professionally than medical students, and vice versa.[5]

When examining sex grouped severity ratings, differences were found. Female learners identified 6 out of 16 vignettes as more severe infractions, as compared to males. Once level of training and sex was controlled for in regression analyses, differences among male and females were found for seven vignettes (misrepresentation, lapse in excellence, inappropriate dress, lack of altruism, disrespect, shirking duty, and abuse of power), with females perceiving professionalism infractions as more severe. Once level of training and sex were both included in regression models, differences between medical students and residents were no longer significant. Other studies have also found students' descriptions of professionalism differed by sex, and females are more likely to label behaviors as unprofessional.[7],[8] Nath et al. found sex differences for 12 out of 29 statements where unprofessional behaviors were depicted, and significant differences were due to females rating behaviors as unprofessional.[8] Midik et al. also state a student's sex is an influential component of their concept of medical professionalism.[7] In our sample, it appeared that sex better predicted professionalism perception when compared to the level of training. While differences in labeling professionalism behaviors may differ related to one's sex or other factors,[8] it is important to note the findings reflect professionalism in theoretical situations, and severity ratings may not translate into actions taken in real situations.

While this study provided valuable information on the measurement of professionalism based on behavior vignettes in a Canadian sample of medical learners, there are several limitations. First, the survey is cross-sectional, therefore, changes in perception of professionalism in an individual was not examined over time. Second, the findings were obtained for and can only be generalized to individuals who participated in the survey at our institution. While the response rate was in the expected range for online data collection,[9] it is unclear how representative this sample was of the entire population.


  Conclusion Top


In summary, the current study reflects the ratings of professionalism behaviors from a sample spanning all medical specialties at the multiple levels of training. Future work is needed in the area of professionalism and sex to understand why female and male learners may perceive professionalism differently and also to utilize these findings in the teaching and evaluation of professionalism initiatives and policies. This study adds to the literature and supports the consensus that perceptions of what constitutes professional or unprofessional behaviors are based on multiple factors.

Acknowledgments

The authors would like to thank Yunqiao Wang for reviewing the article.

This study was financially 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). The funding sources had no role in the design and conduct of the study; no role in the collection, management, analysis, and interpretation of data; and no role in the preparation, review, and approval of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nagler A, Andolsek K, Rudd M, Sloane R, Musick D, Basnight L. The professionalism disconnect: Do entering residents identify yet participate in unprofessional behaviors? BMC Med Educ 2014;14:60.  Back to cited text no. 1
    
2.
Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: A cohort study. Med Educ 2004;38:522-34.  Back to cited text no. 2
    
3.
Kulac E, Sezik M, Asci H, Doguc DK. Medical students' participation in and perception of unprofessional behaviors: Comparison of preclinical and clinical phases. Adv Physiol Educ 2013;37:298-302.  Back to cited text no. 3
    
4.
Borrero S, McGinnis KA, McNeil M, Frank J, Conigliaro RL. Professionalism in residency training: Is there a generation gap? Teach Learn Med 2008;20:11-7.  Back to cited text no. 4
    
5.
Spiwak R, Mullins M, Isaak C, Barakat S, Chateau D, Sareen J. Medical students' and postgraduate residents' observations of professionalism. Educ Health (Abingdon) 2014;27:193-9.  Back to cited text no. 5
    
6.
Stern D. Measuring Medical Professionalism. New York: Oxford University Press; 2006.  Back to cited text no. 6
    
7.
Midik O, Bati A, Tontus O. What is medical professionalism? What do students think? Eur J Res Educ 2014:139-44.  Back to cited text no. 7
    
8.
Nath C, Schmidt R, Gunel E. Perceptions of professionalism vary most with educational rank and age. J Dent Educ 2006;70:825-34.  Back to cited text no. 8
    
9.
Saldivar MG. A Primer on Survey Response Rate. Learning Systems Institute, Florida State University: 2012. Available from: https://mgsaldivar.weebly.com/uploads/8/5/1/8/8518205/saldivar_primer_on_survey_response.pdf.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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