Brownell, A. Keith W. MD; Côté, Luc MSW, PhD
Medical professionalism and the profession of medicine are attracting considerable attention in the medical literature, particularly with regard to the need for teaching about these topics during undergraduate and residency education.1–7 Yet, despite this discussion, few data are available to indicate what medical students, residents, or even practicing physicians actually know about the topics. Therefore, we assessed senior residents' views about professionalism and how they had learned about it; the results of which are reported here.
During the 1998-99 academic year, we invited all senior residents at Laval University (LU) (n = 334) and the University of Calgary (UC) (n = 199) to participate in this study. We defined a senior resident as any resident in one of the following groups:
▪ year two of a family medicine program;
▪ year three (and beyond) in a Royal College of Physicians and Surgeons of Canada (RCPSC) primary certification program;
▪ any subspecialty program; and
▪ any non-accredited training program beyond a primary certification or subspecialty program.
Medical and surgical specialties and subspecialties were classified according to the listing used by the RCPSC.
For this study, we used a modified Dillman8 method. In the fall of 1998, we sent all senior residents a package containing a letter of introduction from the investigators outlining the purpose of the study, the methods used to maintain confidentiality, an invitation to participate, the questionnaire, and a self-addressed envelope for returning the questionnaire. About two months later, we sent to non-responders a second mailing that contained a letter of introduction along with all the material that had been circulated with the first mailing. About a month later, we carried out a third mailing to non-responders with the same material. To maintain the confidentiality of both respondents and non-respondents, neither of the investigators took part in developing the nominal—numerical lists, the handling of returned questionnaires to determine who had responded, or the construction of the lists for any of the three mailings.
The questionnaire was developed specifically for this study and was field tested on a small number of residents and faculty before being finalized. The questionnaire collected demographic data that included each resident's training level, program, gender, and age. We asked each resident to list five words or phrases (attributes) he or she associated with the term professionalism and to rank-order a list of seven methods (including an option to write in methods not listed) he or she had found most useful for learning about professionalism. The resident was asked to indicate, by means of a Likert scale (ranging from 1 = very inadequate to 7 = very adequate), his or her view on the quantity and quality of teaching about professionalism in his or her program. The resident was asked to list suggestions whereby teaching about professionalism could be improved in his or her program. Again, by means of a Likert scale (ranging from 1 = very uncomfortable to 7 = very comfortable), we asked the resident to indicate his or her degree of comfort in explaining the meaning of professionalism to a more junior trainee. Finally, we asked the resident to name the Canadian medical organization or body he or she believed to be most concerned with matters of professionalism.
One of the investigators (LC) and the research assistant independently carried out an initial content analysis of the qualitative data (triangulation process) as outlined by Miles and Huberman.9 The two investigators jointly carried out the final classification by consensus and then the data were rank-ordered. We calculated means and standard deviations for the quantitative data and subjected the results to multiple regression analysis.
Both faculties of medicine gave ethical approval to the study.
The overall response rate, 48.4% (258 of 533 residents), was virtually identical to that for each of the faculties. Of the total number of residents surveyed, 22.1% were in family medicine, 56.4% were in medical specialties, and 21.5% were in surgical specialties, and those responding, 26% were from family medicine, 51.5% from medical specialties, and 21.3% from surgical specialties. There were 1.2% of respondents who could not be classified because of incomplete data. Women made up 54.8% of the total resident body at LU and 42% of the total resident body at UC, and the response rates for women were 55.3% from LU and 42.7% from UC. The mean ages of respondents, 29.2 years at LU and 31.3 years at UC, were similar to the mean ages for all residents at LU (30.1 years) and at UC (32.1 years).
The 258 respondents listed a total of 1,052 attributes of professionalism. Qualitative analysis yielded 28 groups of attributes (see Table 1). Fifteen of the attributes were selected by 30 or more respondents. The three most commonly listed attributes were (in order of frequency) competence (129), respect (123), and empathy (101), and the three least commonly listed attributes were put patient needs first (6), climate of confidence (4), and balance between personal and professional life (3).
A majority of the residents in either program listed contact with positive role models as their preferred method of learning about professionalism (Table 2), followed by contact with patients and their next of kin, and contact with negative role models.
The mean rating by residents in all programs for the adequacy of the quantity of teaching about professionalism was 4.13 (SD ± 1.44). The mean rating for the quality of the teaching about professionalism was 3.79 (SD ± 1.44). Multiple regression analysis of these data showed statistically significant differences of the responses by university for both quantity and quality of teaching, with these factors explaining 8.8% and 6.8% of the variance, respectively. The most commonly selected suggestions for learning more about professionalism were better examples of teachers as role models (30%, n = 61); discussion with peers, teachers, and patients (23%, n = 47); workshops and seminars (19%, n = 40); and formal teaching (19%, n = 39). The mean of the residents' ratings of their comfort in explaining what professionalism is to a more junior resident was 4.86 (SD ± 1.32). A total of 56% of the residents correctly identified the Canadian medical organization most concerned with professionalism (i.e., either the Collège des médecins du Québec or the College of Physicians and Surgeons of Alberta).
In this study, we wanted to determine the views of residents who were the closest to completing their program, so we sampled the opinions of senior residents only. This still led to a considerable range in the number of years trainees had actually been residents (most family medicine residents were in their second and last year of their program, whereas the specialty and subspecialty residents were all at least in the third year of their training). However, despite differences in years of training, the residents in family medicine listed the same attributes in their top three choices (competence, respect, and empathy) as did the residents in the specialties, which suggests that the year of residency did not make a difference to at least the main attributes the residents chose. Looking at the data by gender, men and women listed the same top three attributes (competence, respect, and empathy). Since there is no other study like ours in the literature, it is impossible to compare directly the list of attributes that emerged from our data with those from other reports. Yet, in our review of articles that list attributes commonly associated with professionalism,1,7,10 we found many of the same terms, which indicates that there are similarities between our findings and those of others, at least qualitatively.
Residents spend the vast majority of their time involved with patient care. In these activities they act as medical experts and clinical decision makers for their patients, they deal with the doctor—patient relationship, and they constantly deal with ethical issues. The importance of personal qualities is much in evidence as they communicate with families, health care team members, other medical and paramedical professionals. The 15 most commonly listed attributes of professionalism we found all relate to one of these categories. For example, the attributes of competence, up-to-date medical knowledge, good clinical judgment, and good organization all relate to residents' activities as medical experts and clinical decision makers. Further, the attributes of respect, empathy, confidentiality, courtesy, and good communication are all related to the doctor—patient relationship; the attributes of honesty and integrity, responsibility, collegiality, self-appraisal, and calm are related to personal qualities; and non-medical issues that figure in the complex decision making that is a common part of management of patients today, especially in the inpatient setting, are related to ethical issues. The larger view of professionalism, which includes the social vision of medicine (i.e., altruism, importance of the social contract, serving the needs of patients and society before one's own, speaking out on behalf of issues within the community), self-governance, and codes of ethics, seemed to be less appreciated by the residents.
In a recent editorial,11 commenting on an article describing residents' choices of attributes of excellent attending-physician role models,12 the relationship between the choices residents made and their daily work was also noted. The editorial stated that since residents spend the majority of their time caring for patients and teaching, it was likely that they would focus on the teachers' behaviors that had the greatest congruence with their daily work. It would also be understandable that they would model themselves on physicians whose careers focused on patient care and teaching.
The importance of role models for residents to learn about professionalism is reflected in the overwhelming number of residents who selected contact with positive role models (first choice by 93.5% of all residents) and contact with negative role models (third choice by 43.5% of all residents). Their second choice, selected by 50% of all respondents, was contact with patients and their next-of-kin. All three of these choices reveal the importance of learning through contact with others, and again, support the validity of classifying the attributes and learning about them in terms of the daily working life of the trainee.
The fact that almost half of the residents (46%) did not correctly identify the provincial licensing body as the Canadian medical organization most concerned with professionalism again points to the fact that residents are less knowledgeable about those aspects of professionalism that do not relate to their current daily activities.
Multiple regression analysis of the data regarding adequacy of quantity and quality of teaching about professionalism showed statistically significant differences in the responses by university for both. However, because these factors explained only 8.8% and 6.8% of the variance, we felt the differences were unlikely to be meaningful in terms of basic differences between the two faculties of medicine.
Two interpretations can be derived from our study's results. One view is that residents have a very incomplete knowledge of what professionalism is, while the other is that residents are developing their knowledge of professionalism in terms of what they actually do and that, although limited in scope, their knowledge is quite good. The latter view, which is the one we favor, holds that what one needs to know about professionalism will change and needs to be continually upgraded and refined throughout the physician's practice life. This means the topic of professionalism needs to be high on the list of topics for life-long learning for physicians. So, just as physicians will find that they must upgrade their knowledge because of advances in science as well as changes in practice focus, similarly, they will need to continually upgrade their knowledge and skills related to professionalism. The aim, then, for residency education programs on professionalism should not be to try to teach the trainee everything during residency. Instead, the aim should be to instill the basic principles and develop the attitude that professionalism is of great importance to the physician at every stage of his or her practice life and that it needs to be tied to life-long learning.
Individual residency programs will have to decide on the topics they plan to focus on in any educational interventions. Our findings and the detailed list of proposed topics for instruction about professionalism that was published recently2 could serve as the starting point for making such decisions.
Although our response rate of 48.4% may be considered somewhat low, we believe that our results are generalizable because (1) there were a large number of responders in total (258), (2) the responders came from two faculties of medicine that are geographically separated by over 4,000 km and in very different parts of Canada (one English-speaking and the other French-speaking), and (3) the individuals who responded were similar in make-up to the overall groups of residents sampled in terms of age, sex, and distribution within the different programs (family medicine, medical specialties, and surgical specialties).
Further research is needed to determine teachers' perceptions of professionalism in medicine and their preferred ways of teaching and learning about it, and the teachers' and residents' perceptions of the social vision of medicine.