Objectives: Although there has been substantial progress nationally in teaching and assessing professionalism during the clinical years,1 much work remains for the early years of medical school, when problem behaviors are often first evident. At the University of California, San Francisco, we enriched our explicit curriculum on professionalism and expanded the clinical years' successful physicianship evaluation to the first two years. The objectives of this program were to promote high professional standards from the outset, to identify problems early, and to remediate rapidly.
Description: Beginning in 1994, we developed an integrated program for promoting and teaching physicianship. During orientation, matriculating students sign a learning contract that includes explicit professionalism principles. Students spend substantial time in small groups and clinical preceptorships during their first two years. These settings facilitate observation of physicianship attributes and provide opportunities to teach professional development at a formative stage. We publish clear criteria for assessing professionalism during early clinical experiences, signaling that these attributes are as important as knowledge and technical skills in the spectrum of clinical learning.
We adapted the physicianship reporting mechanism used in the clinical years to the first two years' courses, focusing on assessing students' reliability, responsibility, self-improvement, adaptability, and relationships with others. A course director concerned about a student's behavior will initially give the student constructive feedback and, if concerns persist, will file a report with the associate dean for student affairs. Remediation, mentoring, and counseling ensue. Substantial concerns raised in the first two years are followed into the clinical years.
Discussion: Our faculty has identified six to eight students per year who need support or remediation, and we have developed individualized plans for them. Our observation so far is that the students with the best outcomes are those who are immature in some way or whose individual temperaments, communication styles, prior experiences, or challenges adapting to the culture of medicine affect their professional behaviors. Those least likely to improve their professional behaviors are students who are poorly motivated, unreliable, irresponsible, and have trouble receiving feedback.
An example of effective remediation is a student who was extremely uncomfortable learning to examine and interview patients. In discussion, it became evident that the student's cultural experience was interfering—his preceptor's geriatrics practice served many patients similar to his grandparents. With this insight, the student was able to talk with his preceptor, and in return receive support and guidance in accomplishing his learning objectives. He also shared this experience with his small group as a valuable cultural-awareness learning experience and as a strategy for problem solving.
The greatest challenge to implementation is to ensure that faculty members understand that signaling a student's deficiencies is helpful rather than punitive. Opportunities to discuss examples of successful early intervention have advanced this understanding most effectively. Further study of student characteristics and differing outcomes is in process.
Creation of an integrated program of promoting, teaching, and evaluating professionalism underscores the school's commitment to students' professional development. The expanded and focused physicianship evaluation process can serve as an outcome measure for curricular impact on students' professional behaviors.
1. Papadaksi MA, Osborn EHS, Cooke M, Healy K. A strategy for the detection and evaluation of unprofessional behavior in medical students. Acad MEd. 1999;74:980–90.
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