Professionalism in Medical Education- Perspectives of Medical Students and Faculty

Background Addressing professionalism in medical education is challenging. Increasing attention has been focused on developing professionalism in medical school graduates. The culture of faculty and the behaviors of medical graduates are often incongruent with professionalism. Objective To assess awareness of medical students and faculty about professionalism and suggest strategies for developing professionalism. Methods Validated questionnaire about professionalism was used. Medical students (n=57) and Faculty (n=50) attending Faculty of Medicine (FOM) King Fahad Medical City Riyadh were included in study. Results Among personnel characteristics, the most highly ranked items were honesty (faculty: 47(94%); students: 35(61.4%) adhering to ethics (faculty: 42(84%); students: 36(63.2%), and reliability in patient care (faculty: 42(84%); students: 35(61.4%).For the interaction with patients category, in highly ranked item was respect for patient (faculty: 44(88%); students: 38(66.7%).Regarding social responsibility, for students highly ranked items was improving access to health care (student: 31(54.4%) whereas faculty designated improving access to health care (faculty 31(62%) more important. With respect to strategies to improve professionalism, the highest ranked strategy across faculty was including in evaluation 29 (58%), while in students individual mentoring 28 (49.1%) was highly ranked strategy for developing professionalism. Rafique M, Nuzhat A, Abdulaziz Enani M MedEdPublish https://doi.org/10.15694/mep.2017.000041 Page | 2 Conclusion The difference in attitudes towards professionalism among students and faculty suggests unification of vision of both. Including in evaluation is better strategy for developing professionalism.


INTRODUCTION
Professionalism is a concept of belief system to achieve trust between physicians and the society. Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served (Epstein RM & Hundert EM. 2002). Professionalism becomes an essential core competence in medical education in context to societal expectations. Medical professionals are expected to have a specified set of behaviors and attitude towards patients and society (Al-Eraky MM & Marei HF. 2015). In the year 1999, professionalism was listed as an ACGME (Accreditation Council for Graduate Medical Education) general competency, and the Medical Professionalism Project was launched by the American College of Physician Foundation, European federation of Internal Medicine and American Board of Internal Medicine (Kirk LM. 2007). According to American Board of Internal Medicine, 1994, core of professionalism is defined as "constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest" (Ludmerer KM. 1999). Professional characteristics of excellence in practice, modesty, recognition of personal limitations; professional judgment; and maintaining a fiduciary relationship with patients are expected to be exhibited in a medical professional rather than traditional qualities for improved service of patients and clinical competence Hilton S & Southgate L. 2007). Educators should assess professionalism by formative and summative evaluation. In addition, 360 degree evaluation by peers, nurses, patients and colleagues is required (Kirk LM. 2007). In a study conducted by Eraky in the year 2012 the participants identified all components of the ABIM (American Board of Internal Medicine) framework of professionalism as appropriate for the Arabian context (Al-Eraky MM & Chandratilake M. 2012). In addition, they indicated professional autonomy as an important component of professionalism. Expert knowledge, self-regulation, and trust are three basic characteristics of professionals (Al-Eraky MM & Chandratilake M. 2012). There are differences in attitudes to professionalism in under graduate and graduated students. Graduated students have more rational approach towards important professional values. Majority of students in most UK medical schools are aware of importance and rationale of teaching professionalism. Role models, the media and parents are most important influencers on developing professionalism (O'Flynn S. et al. 2014). Medical students consider confidentiality, good medical knowledge, practical skill, promptness, hygiene and appearance as important characteristics in context to professionalism (Gale-Grant O. et al. 2013). Good doctor is a palatable concept that students adapt in context to professionalism, whereas they consider professionalism in medical education as an external and forced theory. Since both traditional and professional paradigms compete with each other majority of students favor becoming a good doctor rather than a professional (Cuesta-Briand B et al. 2014). Professionalism can be taught, learned, and assessed.
Teaching professionalism might fulfill patient expectations; develop association between professional and improved clinical outcomes and help in accreditation of organization (Mueller PS. 2009). Professionalism is a key measure of the effectiveness of the medical students in future but adopting professionalism is possible by clear development of ethics and agenda and also by developing the appropriate assessment method of professionalism (Whitcomb ME. 2002). Medical students of foundation years 1 and 2 in UK consider that medical professionalism is poorly taught and assessed and desire it to be taught and assessed it as individual entity rather that within medical ethics (Esen UI. 2013).
There is significant difference in how professionalism is taught and how graduates wish it to be taught with more effectiveness. According to the doctors and medical students in County Durham and Darlington Foundation Trust Role models and learning through experience were identified as being the most useful sources for teaching professionalism whereas lectures and online teaching were not felt by many to be valuable resources (Riley S & Kumar N. 2012). Teaching of professionalism should integrate with difficulties of medical practice to overcome the apparent strains among medical students (Cuesta-Briand B et al. 2014). Role of faculty leaders in medical schools and teaching hospitals in defining and constructing means of teaching and evaluating professionalism is important. Faculty members should be evaluated for the role in professionalism development in annual performance meeting with dean (Whitcomb ME. 2002). Institutional cultures play an important role in the development of student's attitude and behavior (Whitcomb ME. 2002). In order to have an effective system of teaching and evaluation of professionalism, there is need of refreshing the knowledge of faculty members and teachers about professionalism as well as they should be aware and skilled to evaluate professionalism effectively (Steinert Y et al. 2005). Professionalism is not a static quality, it improves with changes in accepting ethics and morality and with legislative changes both in government and within organizations (Henning MA et al. 2005).

OBJECTIVE
To assess the awareness of undergraduate medical students and faculty about professionalism in medical 1. profession.
To recommend potential strategies for developing professionalism 2.

MATERIAL AND METHOD
Institutional review board (IRB) approval was obtained (IRB approval no-15-178), from King Fahad Medical city. A prospective cross sectional study was designed. We have used validated questionnaire regarding attitudes towards professionalism, utilized in previous studies (Morreale MK et al. 2011). Author's permission to use questionnaire was taken prior to its use. Survey tool items were initially constructed based on review of the literature concerning the development of professionalism in medical students. The items in the questionnaire address four categories which are Personal characteristics; Interaction with patients; Social responsibility; and Interactions with the healthcare team. Rating of these criteria was done on an ascending 5-point Likert scale with rating options: Not at all important, somewhat important, neutral, important and very important.
Participants were selected by convenience sampling. Our participants were undergraduate medical students, 3rd year (males=18, females=24),4th year(males=29), 5th year (males=21), total (57) from Faculty of Medicine, King Fahad Medical city , KSAUHS and Faculty members (n=50) from basic medical sciences as well as clinical sciences were included. Voluntary participation with verbal consent was done.
Data was collected from students of Faculty of Medicine (FOM), King Fahad Medical City , King Saud Bin Abdulaziz University of Health Sciences Riyadh and faculty members. they were approached during their free time to complete paper based questionnaire. Demographic information of students regarding age, gender, grade of study, previous qualification were noted. For the faculty members, we had noted gender, specialty, academic position, The Likert scale data was coded where not at all important =1,and very important=5. Data analysis was done on SPSS version 22 (IBM). Descriptive statistics were calculated for each domain and item of each group separately. Independent t test was carried out to see difference in responses between students, and faculty. Statistical significance was set at p value of less than 0.05.

RESULTS
Questionnaires measuring attitudes towards professional behaviors from medical students were analyzed, with the following response rates: 3 rd and 4 th year students 62% (57/92) and faculty members 71 % (50/70).  For the interaction with patients category, faculty rated respect for patient (P = 0.021) as significantly more important, and there was a significant trend towards increased ratings for confidentiality (P = 0.026). For both groups, the highly-ranked item was respect for patient (faculty: 44 (88%); student: 38(66.7%).
For social responsibility, there were no significant differences between both groups with respect to importance ratings expect for treating the underprivileged (P = 0.012). For students, the two most highly ranked items were improving access to health care (student: 31(54.4%) and manage conflict of interest, (student: 27(47.4%) whereas for the faculty the items were improving access to health care (faculty 31(62%) and justified distribution of resource (faculty: 30(60%).
For interaction with healthcare team category items, no significant differences in importance ratings were found between students and faculty.
With respect to strategies to improve professionalism, the highest ranked strategy across faculty was including in evaluation 29 (58%), followed by observing and modeling 24(48%). While in students individual mentoring 28 (49.1%) was highly ranked strategy followed by observing and modeling 26 (45.6%), for developing professionalism.

DISCUSSION
While both faculty and students generally rated each of the four professionalism category items as either "important" or "very important", faculty ratings were higher on average. Faculty attributed greater importance, relative to students, to various aspects of professionalism across the personal characteristics, interaction with patients and social responsibility categories. For both groups, the most highly ranked items were Honesty, Adhering to ethics and reliability in patient care. Additionally, in students, a significant decrease in perceived importance of the following professionalism items was evident: punctuality, attendance and appearance.
For the Personal characteristics and Interaction with patient, the difference in opinion of faculty and students can be due to prior exposure to work environments and practices. This difference may reflect greater maturity in terms of ethical orientation and intellectual/emotional maturity (James D et al. 2009). In our study the difference in opinion among students and faculty is significant in regards to internal motivation, punctuality and attendance, reliability in patient care, knowledge of limits, honesty, response to assessment, avoiding abuse of power and adhering to ethics.
Medical students consider confidentiality, good medical knowledge, practical skill, promptness, hygiene and appearance as important characteristics in context to professionalism (Gale- Grant O et al. 2013). Although in our study confidentiality constitute a statistically significant trait, appearance did not prove to be as important to professionalism.
An additional concern arising from this study is concerning students' attitudes to attendance and punctuality. Mary Morreale conducted a study in 2011, and reported that resident physician's mean scores were highest for each professionalism category when compared to medical students indicating the value of professional behavior (Morreale MK et al. 2011). In our study, almost similar results were produced showing more importance to professional behavior by faculty members when compared to medical students (Phillips SP & Clarke M. 2012).
Honesty is the highly-ranked trait that is supported by faculty members for professionalism whereas respect other members is chosen by students. Eraky, in the year 2015, reported that trust between physician and society is the cornerstone of medical professionalism (Al-Eraky MM & Marei HF. 2015).
There is a lack of agreement for teaching professionalism either by formal curricular activities or to be expressed informally between mentor and mentee in clinical environments ( university of Washington concluded that increased attention to teaching and modeling professionalism among faculty, residents, and staff help in increased awareness of students (Goldstein EA et al. 2006). Whereas in our study both students and faculty consider including professionalism in evaluation as a better strategy for developing professionalism.

CONCLUSION
This study assessed the opinions towards different domains of professionalism in students and faculty. Both students and faculty have difference in emphasis on these domains as well as both have different perspectives regarding how professionalism should be taught. There should be an agreed and unified system of quantifying professionalism keeping in account both students and faculty perspective.

Take Home Messages
Keeping in mind the difference in the attitude to professionalism among students and faculty, we should design a compatible teaching system of professionalism that is well accepted and be motivational for students as well as practicable for faculty for effective teaching.
There is need to unify the concept of professionalism among trainer(faculty) and trainee (students).
Based on our study we suggest that faculty should evaluate professionalism periodically and at the same time students should be individually mentored for improving their behavior.

Notes On Contributors
Munazzah Rafique is a Pakistani physician working as a Medical data Manager in the HIM department of KFMC. She is specialized in Public health and Medical Education.
Dr Ayesha Nuzhat is an Indian Anatomist working in basic medical science department Faculty of medicine, KFMC. She is also specialized in medical education and is a life member of anatomical society of India.
Dr Mushira Enani is Saudi Physician working in department of medicine at KFMC. She is the director of main hospital at KFMC.