Purpose: To examine the relationship between learner experience in the “hidden curriculum” and student attribution of such experiences to professionalism categories.
Method: Using the output of a thematic analysis of 272 consecutive narratives recorded by 135 students on a medical clerkship from June through November 2007, the authors describe the frequency of these experiences within and across student-designated Association of American Medical Colleges–National Board of Medical Examiners professionalism categories and employ logistic regression to link varieties of experience to specific professionalism categories.
Results: Thematic analysis uncovered two main domains of student experience: medical–clinical interaction and teaching-and-learning experiences. From a student perspective the critical incident stories evoked all professionalism categories. Most frequently checked off categories were caring/compassion/communication (77%) and respect (69%). Logistic regression suggested that student experiences within the teaching-and-learning environment were associated with professionalism categories of excellence, leadership, and knowledge and skills, whereas those involving medical–clinical interactions were associated with respect, responsibility and accountability, altruism, and honor and integrity. Experiences of communicating and working within teams had the broadest association with learning about professionalism.
Conclusions: Student narratives touched on all major professionalism categories as well as illuminating the contexts in which critical experiences emerged. Linked qualitative and quantitative analysis identified those experiences that were associated with learning about particular aspects of professionalism. Experiences of teamwork were especially relevant to student learning about professionalism in action.
Dr. Karnieli-Miller is assistant professor, Department of Community Mental Health and Center for Excellence in Patient–Professional Relationships in Health Care, University of Haifa, Haifa, Israel.
Dr. Vu is director of internal medicine clerkships and assistant professor of clinical medicine, Department of Medicine and Roudebush VAMC, Indiana University School of Medicine, Indianapolis, Indiana.
Dr. Frankel is professor of medicine and geriatrics and senior research scientist, Regenstrief Institute and Roudebush VAMC, Indiana University School of Medicine, Indianapolis, Indiana.
Dr. Holtman, at the time of writing, was director, Developmental Programs, National Board of Medical Examiners, Philadelphia, Pennsylvania.
Dr. Clyman is executive director, Center for Innovation, National Board of Medical Examiners, Philadelphia, Pennsylvania.
Dr. Hui is associate professor, Division of Biostatistics, Department of Medicine, and senior biostatistician, Center for Aging Research, Indiana University School of Medicine, and senior scientist, Regenstrief Institute, Indianapolis, Indiana.
Dr. Inui is president and CEO, Regenstrief Institute, and Sam Regenstrief Professor of Health Services Research and associate dean for health care research, Indiana University School of Medicine, Indianapolis, Indiana.
Please see the end of this article for information about the authors.
Correspondence should be addressed to Dr. Karnieli-Miller, Department of Community Mental Health, University of Haifa, Haifa, 31905, Israel; telephone: (+972) 48288643; fax: (+972) 48288723; e-mail: OritKM@gmail.com.
First published online January 18, 2011.
Our team had a patient with terminal small-cell lung cancer for which no further treatment could be done. Instead of dealing with the topic of the patient's death with just our team, we consulted the palliative care team. We met together first, discussed the patient's options, the goals of the patient, the goals of his family members, and our recommendations as the medical team in charge of his care. We came up with several end-of-life scenarios from which the patient could actively choose how he would live out the rest of his days. We then met with the family, four physicians, a nurse and me, a medical student. There were three family members present and the patient. At first, I wondered if the presence of so many people in white coats would be intimidating or offensive to the family, and thus inappropriate, but I was encouraged to attend by my attending and resident physicians. During the meeting, the patient's situation was addressed honestly in a straightforward manner. However, there was an obvious compassionate atmosphere created by the family members as well as from the large group of medical professionals demonstrating to the family that they care about the future of this patient. We maintained that the patient's goals were our primary goals, and the family's concerns were addressed individually and extensively. There was no stone left unturned, and no questions left unanswered. This was a discussion about the patient's death that had no underlying context of fear, avoidance or denial about the reality the patient faced. I think that this was the most appropriate way to handle the impending death of a patient without behaving like death is the enemy, but rather preparing to make a patient's death as comfortable and easy as possible for all involved.
Third-year, male medical student's professionalism narrative; professionalism categories checked off: altruism, respect, caring/compassion/communication
In recent years, narrative writing and reflection in various forms have been widely used to enhance professional development and inculcate professional values.1–4 The rationale for using student narratives is a belief that the lived experience of students and their day-to-day immersion in this informal or “hidden” curriculum are a powerful influence on their professional development.5–7 These experiences influence students' socialization into the norms and rituals of the organization, teach the conventions of interpersonal processes between students and teachers and patients and physicians, and demonstrate the complexities of relationships with other professionals.8 The breadth and diversity of these particular experiences may be vast and difficult to comprehend or synthesize because students are exposed to various positive and negative role models and to different experiences as observers and participants in processes of patient care, teamwork, and teaching and learning.7,9 Exposure to these experiences, and specifically to negative role modeling, may increase the likelihood of becoming cynical and adopting negative professional attitudes and behaviors.10 Reflective writing and feedback may mitigate this risk. Selecting one experience from among many could be described as an act of discernment.11 Organizing a coherent description of context and action organizes and frames the experience. This reflective process is further enhanced when there is an opportunity for thoughtful reflection on an incident and one's point of view is established. This last activity (personal reflection) may lead to a higher level of learning from experience,12 one that has the potential to bridge theory and practice, moving learner knowledge in the direction of phronesis (practical knowledge or wisdom in action), in many ways a critical capacity for professionals in performing fields such as medicine.13,14 Writing about one's own experiences and observations in reflective essays and telling them through writing expands the ability to recognize the layered consequences of the phenomena, focuses one's attention on what is happening to the other, and represents what has been witnessed.2 Recent publications have indicated that the level of reflection and learning from these essays may be further enhanced by specific faculty and peer feedback.15
The present study focuses on examining the relationship between medical students' learning experiences in the hidden curriculum and how they attribute these experiences to the categories associated with professionalism. Though narrative and reflection are in frequent use, we have not been able to find empirical research in the medical literature that would suggest which specific experiences in our working environments teach students about particular elements of professionalism. Instead, we uncovered only general statements about narrative reflection leading to better understanding of the professionalism categories discussed in the professionalism competency curriculum16,17 and specific examples of deeper exploration of a particular category or term, such as respect.16 Additionally, we have found no empirical studies examining whether all widely accepted domains of medical professionalism are discernable in students' critical incident narratives and whether these narratives might serve as a suitable resource for professional development seminars or small-group dialogues intended to serve as safe environments needed for reflection.17,18
At the Indiana University School of Medicine (IUSM), student narratives are used in all years as a pedagogic strategy to promote student maturation in the professionalism domain of the competency-focused curriculum. Among other uses, the third-year medicine clerkship requires students to record two Health Insurance Portability and Accountability Act–compliant critical incident narratives in a secure personal “professionalism journal.”19 The thematic analysis of the journal entries has been described elsewhere.9 The present study focuses on the relationship between the domains and themes in the student journal entries and the Association of American Medical Colleges–National Board of Medical Examiners (AAMC–NBME)20 categories of professionalism checked off by the students in completing the assignment. Our specific aims were to
* assess the extent to which student experiences covered widely accepted categories of medical professionalism,
* ascertain which kinds of experiences were most strongly associated with student learning about categories of medical professionalism, and
* assess the extent to which reflective dialogue focused on a limited number of student-selected narratives might also cover the major categories of medical professionalism.
Many terms, definitions, and taxonomies of professionalism are available in the broad-ranging literature that describe the attributes of the “good” physician, professional values, professional ethics, and commitments of medicine.5,21–23 One taxonomy that might be considered a reasonable gold standard emerged from a working conference cosponsored by the AAMC and NBME.20 The qualities of the good physician in this formulation were captured in eight categories: (1) altruism, (2) responsibility and accountability, (3) excellence and scholarship, (4) respect, (5) honor and integrity, (6) caring/compassion/communication, (7) leadership, and (8) knowledge and skills.
The student narratives
Since February 2004, third-year IUSM medical students on their two-month internal medicine clerkship have been required to keep a professionalism journal. Accessing a password-protected Web site, they are asked to record narratives of two rotation experiences, in which they were present as participants or observers, that manifested professionalism (or lack thereof).9,19 After writing the narrative in a free-text area, they also check off any of the eight professionalism categories that they consider relevant to their experience. At the end of the clerkship, the clerkship director—the only person who has access to these narratives—collates and duplicates them for use in a small-group discussion. Group members first read through all of the narratives and then are asked to identify and read aloud one or more that caught their attention. A faculty-facilitated discussion of professionalism issues embedded in the selected narratives then ensues. Once the discussion is completed, the narratives are warehoused until the students graduate (to assure students that they are protected from any risk of reprisal). The IUSM institutional review board has approved the use of graduates' narratives for feedback, research, and publishing (approval # 0303-73),9,16 as other ethics committees have done.12
We examined the entire group of narratives written during a six-month period and the subset of student-selected narratives discussed in the small groups. The primary data for this study were 272 written narratives entered into the professionalism journal by 135 third-year medical students during a six-month period from June through November 2007. During this period, 137 students rotated through their medicine clerkship. Of those, 113 (82.5%) students recorded two narratives, 12 (8.8%) recorded three, 10 (7.3%) recorded one, and 2 (1.4%) recorded none.
We used several statistical analyses to explore the relationships between the students' experiences (domains and themes) that emerged in our earlier thematic analysis9 and the professionalism categories checked off by the student–authors. First, we tabulated students' experiences within and across each professionalism category and then tested the significance of the association between each type of experience with each professionalism category using chi-square (or Fisher exact) tests for two-by-two tables. Second, we used logistic regression models to predict students' preferential choice of specific professionalism categories (dependent variable) from varieties of experience in the narratives (independent variables). Candidate predictors for these final regressions included all experiences that had been associated with a professionalism category at P < .2 in chi-square tests, and additional covariates indicating the gender of the student and the presence or absence of a positive experience in the narrative. Third, to examine whether the faculty-facilitated small-group discussion covered all professionalism categories (at least over time), we examined the frequency and distribution of the critical incident experience types and professionalism categories in the 27 narratives selected by students for discussion in their professionalism seminars during the study period.
Brief overview of student experiences
The analysis of students' experiences was rooted in the free-text narratives and the natural language of student “lived” experience, not in any predefined categorical language drawn from specific literature about professionalism. Some of the themes describing student experiences, nevertheless, used well-known values and behavioral terminology related to professionalism, such as respect, caring, and responsibility, whereas other student narratives included behaviors not specifically cited elsewhere in the professionalism literature, such as capitalizing on teaching opportunities, creating an (un)welcoming environment, and spending time taking care of patients, patients' education and understanding. Our analysis of student experience uncovered two large domains: descriptions of medical–clinical interactions (81.8% of narratives) and description of interactions in the teaching and learning environment (18.2% of the narratives). Medical–clinical interactions included observations of various role models interacting with patients, families, coworkers, and colleagues. Teaching and learning environment interaction narratives were accounts of students' experiences as learners in the clinical setting. A more detailed description of these narrative themes and exemplar narratives can be found in Karnieli-Miller et al9 (2010). During the analysis process of this study, a few small changes were made in the original classification for greater clarity. One subcategory in the initial analysis that focused on taking full responsibility for patient care was moved to the theme of demonstrating responsibility; another theme, going above and beyond and caring and altruism, was split into two separate themes (each accounting for 11 narratives). These changes were made a priori rather than a posteriori (after regression analyses).
Distribution of students' experiences within and across professionalism categories
Table 1 shows the associations students made between their experiences and the categories of professionalism. More than three-fourths (77%) indicated that more than one category was relevant to their narrative. Students checked off a mean of 2.9 categories for each narrative (SD = 1.8, range 0–8), suggesting that the narratives are rich with heuristic value.
Table 1 also illustrates that the distribution of identified experience varieties spanned all eight professionalism categories. The most frequently selected categories were caring, compassion, and communication (checked off in 77% of the narratives) and respect (checked off in 69%). These categories were seen as relevant to many varieties of medical–clinical interactions, most frequently manifesting respect, followed by managing communication challenges and spending time on patient education. The third most frequently selected professionalism category was responsibility and accountability. All other professionalism categories were checked in at least 20% of the narratives, except for excellence and scholarship (16%), which was most often seen as relevant to capitalizing on teaching opportunities in the domain of the teaching and learning environment.
The most frequent student experience, classified as manifesting respect, accounted for 26.8% of all narratives and the plurality of experience varieties within five of the eight professionalism categories (>20% each), especially in the categories of respect (accounting for 33.2% of student experiences producing check offs in this category) and honor and integrity (31.3%). The next-most-frequent kinds of student experience were those classified as managing communication challenges, spending time on patient education, and demonstrating responsibility. All three were associated with relatively high-frequency selections of professionalism categories (accounting for 8.4%–23.6% of all checked off items). Capitalizing on teaching opportunities, within the teaching and learning domain, was most often associated with check offs in two professionalism categories: excellence and scholarship (accounting for 27.3% check offs) and knowledge and skills (accounting for 20.9% of check offs).
Prediction of professionalism categories from students' experiences
Table 2 displays associations between varieties of students' experiences and professionalism categories that are specific to the pair, as demonstrated by logistic regression models. For example, altruism was checked significantly more often when students described experiences that involved communicating and working in teams and experiences with role models demonstrating caring and altruism. Even though manifesting respect was the most frequently identified experience among all narratives when students checked off altruism (Table 1), the percentage of this experience was not significantly higher than in other kinds of narratives that did not check altruism as the professionalism category. As a consequence, when using logistic regression, there was no significant relationship between this kind of experience (manifesting respect) and altruism. A student experience with people demonstrating responsibility significantly predicted selection of responsibility as the professionalism category.
The overall pattern in Table 2 shows that check-offs of the professionalism categories excellence and scholarship, leadership, and knowledge and skills were strongly associated with student experiences in the teaching and learning environment domain such as capitalizing on teaching opportunities (OR > 10), with or without experiences of creating an (un)welcoming environment (OR = 8.9). They were also associated with communicating and working in teams (OR ≥ 4.3) and positive narratives (OR ≥ 2.2). Because the professionalism category of caring, compassion, and communication was frequently checked off for narratives involving the majority of student experiences within the medical–clinical interactions domain, but not in experiences in the teaching and learning environment domain (Table 1), there are significant negative associations between the latter two varieties of experience (creating an [un]welcoming environment [OR = 0.2] and capitalizing on teaching opportunities [OR = 0.1]) and the professionalism category of caring, compassion, and communication. All other professionalism categories (i.e., altruism, responsibility and accountability, respect, and honor and integrity) are positively and significantly associated with selected experiences in the medical–clinical interaction domain, as shown in Table 2. The student experience that has a significant relationship with more professionalism categories5 than any other (including altruism, honor and integrity, excellence and scholarship, knowledge and skills, and leadership) is communicating and working in teams (for illustrative quotes, see Table 3).
Among all the narratives, positive narratives were significantly predictive of checking off all professionalism categories, except for the categories of responsibility and accountability and respect. The gender of the student narrative author had no significant relationship with check offs in any of the professionalism categories.
Experiences and professionalism categories present in narratives students selected for discussion
During the six-month study period, 12 small-group discussions were facilitated by two of the authors (T.S.I. and R.M.F.). During that period, 27 out of the 272 narratives were selected by the students for discussion in these groups. Table 4 displays the distribution of student experience and professionalism categories checked off within this subset of narratives.
As shown in Table 4, all professionalism categories were checked off for the narratives selected for discussion. Most of these narratives (85.2%) were about caring, compassion, and communication, and more than half were about responsibility and accountability (55.6%) and respect (55.6%). Except for respect, these numbers were higher than the frequency in the entire group of narratives (85.2% versus 77%, 55.6% versus 45%, and 55.6% versus 69%, respectively). Less frequently chosen for discussion were narratives focusing on excellence and scholarship (11.1%) and on leadership (22.2%), which are related to the teaching and learning environment domain (e.g., capitalizing on teaching opportunities). The frequency of positive (55.6%), negative (37.0%), and hybrid (7.4%) narratives in the subset selected for discussion was similar to their distribution within the general data set.
We hope the findings of this study will be encouraging to faculty in medical schools who have chosen to use reflective narratives as a tool to teach professionalism. The experiences described in the student narratives are diverse and touch on all of the conventional categories of professionalism. This is certainly the case for the overall sample of narratives, and even for the limited number of narratives students chose to discuss in the small-group discussions. Although in other circumstances students do not specifically cite a positive effect of written reflections on their learning of professionalism,24 our data suggest that students do connect their experiences in the hidden and informal curriculum directly and immediately to various dimensions of professionalism.
In comparing the frequency of student check offs of AAMC–NBME20 professionalism categories and our previous analysis of narrative content,9 some differences were apparent. From the students' perspective, for example, most of the narratives were about caring, compassion, and communication, respect, and responsibility and accountability. From the researchers' perspective, the relative prevalence order of these narratives was different: respect, communication, and responsibility. This difference may prevail because the research team made a distinction between caring and communication, and even specifically between the different types of communication (e.g., focused on managing communication challenges, such as breaking bad news, or on educating), as well as between narratives that differed by the type of communication partner (communicating with patients and family members versus communication with teams or students). Our findings support the importance of effective communication to professionalism as emphasized in a recent paper focused on patients', nurses', and physicians' perspectives on professionalism.25 Students expect professionals to communicate clearly, compassionately, and patiently with patients, family members, colleagues, and themselves.
The findings in this study also deepened our understanding of the specific behaviors that may embody professionalism from a student perspective25,26 and of the circumstances in which students are actively learning about professionalism. The behaviors included medical–clinical interactions and the experiences in the teaching and learning environment. The logistic regression analysis results suggest that students differentiate between behaviors that are supposed to be enacted in the clinical setting (i.e., with patients, family members, and colleagues) and those that are seen as important in relationships between themselves and faculty. Behaviors manifesting altruism, responsibility, honor and integrity, and respect are situated in the medical–clinical interaction domain, whereas excellence, leadership, and knowledge and skills are observable in the teaching and learning environment. The findings show that caring, compassion, and communication specifically was negatively (less frequently) associated with checked items in the teaching and learning domain, suggesting that students are not expecting their teachers to be compassionate toward them as students. This is an interesting discrimination among behaviors and expectations, perhaps especially because students themselves are a “vulnerable population” in some learning environments and might even benefit from being treated themselves with compassion and caring. They might then learn how to employ these behaviors in interactions with patients if they experienced it themselves in teaching and learning interactions. In the narratives, they express these thoughts and experiences but connect them as to lack of excellence and/or knowledge and skills, not to caring and compassion. This also underscores the value conflicts27 inherent in the various role expectations that learners have to meet. Ginsburg and colleagues28 argue that learners facing a conflict of professional values often use “dissociation” as a strategy to “step out of” the “double-bind” that such a conflict creates for them. The potential negative impact of dissociative coping strategies on professional identity formation deserves further attention.
One experience, communicating and working within teams, seems to be a key driver for five professionalism categories (in both the medical–clinical interactions and teaching and learning environment domains). Even though relatively few narratives were identified within this theme, these experiences were powerful ones that elicited thoughts of various professionalism categories, possibly indicating the special importance of teamwork for both patient care and student learning. Yet it is interesting that teamwork in itself is not explicitly considered an attribute of professionalism.21 Student narratives, as well as a burgeoning literature in quality and patient safety, may give us pause to reconsider the importance of teams and teamwork as an attribute of professionalism.
The significant relationship between various professionalism categories and positive narratives, and the fact that the positive narratives were in the majority, is reassuring and may alleviate general concerns about overweighting lapses of professionalism27 in the use of narrative and reflection and in the hidden curriculum in general. It seems that students notice, appreciate, and learn about various forms of professionalism from positive (as well as negative) role models, and acknowledge and appreciate actions that reflect positively on us as professionals. In particular, positive narratives seem to be associated with learning about excellence and knowledge and skills.
Our findings come from what we acknowledge may be a unique setting. The study was conducted in one institutional setting and within a single clerkship. In addition, although 272 narratives may be a relatively large number for qualitative analysis, some of the themes had only a few narratives, and our sample size was too small for the logistic regression analyses to be feasible across all varieties of experience. Whatever the limitations of this study, we learned from our own findings and would encourage faculty using narrative and reflection as a pedagogic method for teaching and learning about professionalism in medicine elsewhere to continue in their efforts and to pursue similar research in order to discover the type of behaviors that relate to the theoretical concepts of professionalism in their own environments.
The authors greatly appreciate and thank Mr. Pete Castelluccio for his assistance in the statistical analysis.
The project was sponsored by an ABIM and NBME grant focused on enhancement of an environmental survey based on student and resident input.
The study and use of narratives was approved by the Indiana University School of Medicine institutional review board.
An earlier version of this report was presented as a poster at the Society of General Internal Medicine (SGIM), April 30, 2010, Minneapolis, Minnesota.
1Charon R. Narrative medicine: A model for empathy, reflection, profession and trust. JAMA. 2001;286:1897–1902.
2Charon R. Narrative medicine: Attention, representation, affiliation. Narrative. 2005;13:261–270.
3Fischer MA, Harrell HE, Haley H, et al. Between two worlds: A multi-institutional qualitative analysis of students' reflections on joining the medical profession. J Gen Intern Med. 2008;23:958–963.
4Inui TS, Cottingham AH, Frankel RM, Litzelman DK, Suchman AL, Williamson PR. Supporting teaching and learning of professionalism—Changing the educational environment and students' “navigational skills.” In: Creuss RL, Creuss SR, Steinert Y, eds. Teaching Medical Professionalism. Cambridge, UK: Cambridge University Press; 2009:108–123.
5Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.
6Hafferty FW. Professionalism and the socialization of medical students. In: Creuss RL, Creuss SR, Steinert Y, eds. Teaching Medical Professionalism. Cambridge, UK: Cambridge University Press; 2008:53–72.
10Branch WT. Supporting the moral development of medical students. J Gen Intern Med. 2000;15:503–508.
11Branch WT. Use of critical incident reports in medical education. A perspective. J Gen Intern Med. 2005;20:1063–1067.
12Stark P, Roberts C, Newble D, Bax N. Discovering professionalism through guided reflection. Med Teach. 2006;28:25–31.
14Schon DA. Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. San Francisco, Calif: Jossey-Bass; 1987.
15Chretien K, Goldman E, Faselis C. The reflective writing class blog: Using technology to promote reflection and professional development. J Gen Intern Med. 2008;23:2066–2070.
16Karnieli-Miller O, Taylor AC, Cottingham AH, Inui TS, Vu TR, Frankel RM. Exploring the meaning of respect in medical student education: An analysis of student narratives. J Gen Intern Med. 2010;25:1309–1314.
17Bell SK, Wideroff M, Gaufberg L. Student voices in Readers' Theater: Exploring communication in the hidden curriculum. Patient Educ Couns. 2010;80:354–357.
18Suchman AL, Williamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS; Relationship-Centered Care Initiative Discovery Team. Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school. J Gen Intern Med. 2004;19:501–504.
19Inui TS, Cottingham AH, Frankel RM, et al. Educating for professionalism at Indiana University School of Medicine: Feet on the ground and fresh eyes. In: Wear D, Aultman JM, eds. Professionalism in Medicine: Critical Perspectives. New York, NY: Springer; 2006:165–184.
20Embedding Professionalism in Medical Education: Assessment as a Tool for Implementation. Report From an Invitational Conference Cosponsored by the Association of American Medical Colleges and the National Board of Medical Examiners. Washington, DC: National Board of Medical Examiners; 2003.
21Stern DT. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006.
23Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226–235.
27Kirk LM. Professionalism in medicine: Definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007;20:13–16.
28Ginsburg S, Regehr G, Lingard L. To be and not to be: The paradox of the emerging professional stance. Med Educ. 2003;37:350–357.