Professionalism is one of the most important aspects of medicine and yet perhaps one of the most difficult to define. Of course, we all know it when we see it in a colleague. The doctor who is a role model to others, one who is respected and admired not only for their competence but for their attitude to other professional colleagues but especially to patients and their carers. It used to be assumed that if students spent long enough in the clinical environment then professionalism would merely osmose into them from the staff around them but sadly this is not the case. Therefore, we need to teach professional values and model professional values and because students particularly value areas of the curriculum that are assessed we need to examine that our students demonstrate professionalism in their everyday actions.

Why is professionalism important?

Reports from medical regulators around the world reveal that a lack of professionalism is a common cause of referral by patients and employers. In 2004 Papadakis et al [¹] produced the first paper showing that doctors who had been reported to state licensing boards for matters relating to professional misconduct frequently had had similar issues whilst attending medical school. This was an important finding because up until this publication, although teachers had had strong impressions that this was the case, there had not been specific evidence to support this impression. Although a retrospective study this paper together with others went on to provide the impetuous for medical schools around the world to consider how they might incorporate teaching and assessing professionalism into their curricula.

As stated above professionalism has been difficult to define and there have been multiple attempts to do this. I offer the definition and description which was derived from the work that the Royal College of Physicians of London undertook in 2005 [²] as a useful start for faculty new to the area:

When should we teach professionalism in medical schools?

Some have argued that professionalism cannot be taught until the student understands what it means to be a doctor thereby leaving the subject until the later clinical years. However, it is likely that this is too late with patterns of unprofessional behaviour becoming established and more difficult to remediate. Starting to discuss the concept of medical professionalism with first year students allows them to begin to discuss ideas of what it means in practice and to reflect of interactions that they have witnessed, both good and bad, in their own or their family's dealings with healthcare professionals or have seen whilst in healthcare environments. In my own institution, we bring in discussions about medical professionalism in several parts of the early years of the course; for example, in the area of medical ethics teaching, discussions of the duties of a doctor, personal health and wellbeing as well as in the more direct encounters with patients. We are extremely fortunate in Leeds in that we have nearly two hundred patients and carers who work alongside medical educationalists and teachers as partners in the training of our students. The input from this group around the importance of professionalism in contributing to the crucial development and maintenance of trust between doctor and patient and the medical profession and society cannot be underestimated. However, the concept of professionalism should not be confined to considering how medical students interact with patients and their carers but interactions with peers, colleagues and other staff. For example, the responsibility to take their role as part of team or problem based learning, or to ensure they hand in required information to administrative staff in a timely fashion. These things are often over looked but form part of become a medical professional and need to be understood by students at the outset.

How should we teach medical professionalism?

Although the importance of everyday encounters with more senior healthcare staff as role models should not be underestimated, if students don’t examine and reflect on these encounters potentially they lose out on this influential learning experience. Asking students to recount a particular encounter from their clinical experience and to reflect on the professionalism of the staff involved and then challenging students to reflect on what this means for their own professional behaviour is very useful. Involving senior staff who have a high profile in the medical community who are prepared to share incidents in their own careers where they have not behaved with the high standards of professionalism which is their norm and how they have dealt with these events is very valuable. This enables students to understand that individuals are not just categorised as professional or unprofessional but that all of us can have episodes in our careers when we fail to behave as we should but that learning from these events and putting plans or actions in place to prevent the recurrence of such episodes is the most important outcome.

Assessment of professionalism

Assessment of a student's professionalism usually means assessing observed behaviours as getting students to reveal underlying attitudes to a particular behaviour is difficult. Like other kinds of assessment this needs to start early and be part the programme of assessment in the school. There need to be many different types of assessors and the assessment should occur in different contexts so that the needs for reliability and valid of the assessment are fulfilled. The requirement for detailed feedback and face to face discussion is particularly important for those students whose professionalism is felt to fall short on an actual occasion. Getting the student to discuss and explain why the behaved in a certain way can be particularly revealing especially if they divulge the underlying motives for their actions. The Faculty involved in this in-depth assessment need to be supported in developing their ability to tease out underlying issues and biases and also to provide skilled feedback, supporting students to develop plans for improvement. There are now several assessment tools which can be used to assess professionalism for example, multisource feedback and the P-Mex assessment measure which is designed specifically to assess professionalism [³]. Perhaps the most important difference in assessing professionalism compared to other areas such as knowledge and skills, is that professionalism assessment needs to be longitudinal because we are looking for patterns of behaviour that continue to be repeated even though these actions are brought to the attention of the individual as being undesirable in a future doctor. Repeated lapses in professionalism indicate either that an individual is unable to change their behaviour or more commonly that they have no insight as to why the behaviour is inappropriate. Either way these students present particular problems and in extreme cases mean that such students will need to be required to leave the course.

Providing students with ways of remediation for unprofessional conduct is not easy. At Leeds using work that a colleague and I have undertaken on professionalism we are using the theory of planned behaviour first described by Ajzen [⁴]. In this work, behavioural intent and consequent behaviour are influenced by three things: the individuals view of the behaviour, their belief about being able to perform the behaviour and the cultural norm to the behaviour. Using this framework to dissect student behaviour and the understand the prevailing culture we feel that we can support students in examining their underlying attitudes and changing their subsequent actions. We have recently published details of our work in this area together with case study examples which readers might find useful [⁵].

In summary, the development of professionalism is important for medical students. Professionalism needs to be explicitly taught and assessed and not left to passively osmose into students. Like other areas such as knowledge and skills it needs to be part of the programme of assessment of an institution. However, in professionalism the assessment needs to be undertaken longitudinally with each new assessment building on the previous one to ensure that patterns of poor behaviour are identified and if possible corrected. Remediation is possible but is not easy in students with little or no insight and in then end poor professionalism maybe a reason for students to exit the medical course if we are to avoid further and possible more serious problems later in their careers.