Medical professionalism has gained global attention over the past decade.1–4 Ninety professional organizations worldwide have endorsed the Physician Charter,5 which, while acknowledging the diversity of medical practices and traditions in its preamble, reaffirms “the fundamental and universal principles and values of medical professionalism” based on common themes identified by the representatives from the American Board of Internal Medicine, the American College of Physicians and American Society of Internal Medicine, and the European Federation of Internal Medicine.6,7
The editor of the Physician Charter5 asks, “Does this document represent the traditions of medicine in cultures other than those in the West, where the authors of the charter have practiced medicine?” Before this issue was examined further, organizations adopted the charter quickly across specialties and countries internationally.5 As a result, non-Western countries are adopting medical professionalism according to the North American forms of accreditation standards for both undergraduate and graduate medical education.8,9 The Accreditation Council for Graduate Medical Education (ACGME) has set up an international division (ACGME-I) to answer requests from international residency programs to ensure that these programs meet ACGME-I standards, including guidelines for professionalism.10 In Taiwan, where our study takes place, the regulatory body for postgraduate training adopted the ACGME's six competencies, including professionalism.11 The agency that accredits Taiwan's medical schools is also in the process of revising its standards according to the Liaison Committee on Medical Education standards, which includes a new standard on professionalism.12
Even as agencies and professional organizations adopt standardized guidelines for professionalism, scholars continue to emphasize that professionalism is context dependent13 and is a social construct.3 This social construct is defined within a sociocultural context at a particular time. Some sociologists raise the issue that, whereas influential scholars, groups, and organizations in North America and Europe dominate the discourse of medical professionalism,14 there is a paucity of literature on the universal applicability of this framework.15–17 This study addresses a gap in the literature by developing a non-Western framework and comparing it with known Western frameworks. We propose to adopt sound methods to construct a professionalism framework that accounts for non-Western historical and sociocultural contexts. We illustrate this process with a case study in Taiwan.
Medical professionals in Taiwan have enjoyed much respect and autonomy since the Japanese established the first medical school here during their 50 years of colonial rule between 1895 and 1945. In the decades that followed, medical professionals not only provided medical and public health services but also played active leadership roles in the modernization and democratization of the country. The establishment of the National Health Insurance in 1995 limited the total budget of medical institutions, which put financial pressures on physicians to control cost and to increase profit. As physicians became increasingly interested in services not covered by the National Health Insurance, such as cosmetic treatments, their professional image eroded.18,19 In response to these public concerns, especially about doctors prioritizing self-interest over patient interest, medical educators in Taiwan are contemplating how to cultivate the qualities of a desirable physician.20
Our institution, National Taiwan University College of Medicine (NTUCM), serves as an example of a university seeking to address its nation's pursuit of medical professionalism. Historically, NTUCM was the first medical school established in Taiwan by the Japanese during their governance of Taiwan. Historic icons depict our institution's professionalism tradition. The NTUCM Medical Humanities Museum, for example, located in a Japanese-constructed building, is a symbol of medical professionalism education with Hippocratic-like oaths in Japanese on display and the World Medical Association's Declaration of Geneva21 inscribed on the entrance wall. As we considered our institution's professionalism traditions, we also accounted for current influences; today, the majority of the current faculty received their advanced training and/or degrees from the United States.22
The process we describe in this report addresses these complex historical and modern perceptions and the lack of the concept of “medical professionalism” in traditional Taiwanese culture, where Hippocratic tradition is unfamiliar to nonmedical professionals, and Confucian doctrines are emphasized starting at the elementary education level. Instead of imposing foreign preexisting frameworks or nostalgic doctrines,23 we developed a framework of professionalism for NTUCM de novo. We will discuss the advantages of adopting this framework over known Western frameworks in a Confucian cultural context.
We employed three methods in this study: (1) nominal group technique (NGT), (2) expert committee, and (3) text analysis.
Through literature reviews and consultations of experts, we determined NGT to be an effective and efficient method to elicit group values and derive consensus.24–27 NGT is a structured procedure for gathering insight from groups of people. In the NGT process, all group members have equal opportunity to present their views, all views have equal weight, and the process for everyone to list all their ideas for discussion avoids problems associated with traditional group meetings, such as dominating personalities or obedience to authority.24–26 The method is used in management, clinical guidelines creation, and course evaluation in medical education.27
In our NGT process, we based the selection of participants on the purposive sampling28 method. We asked the chairs of various departments (including internal medicine, surgery, obstetrics–gynecology, pediatrics, nursing, and social work) at the National Taiwan University Hospital to recommend those health care workers (including chief residents, attending physicians, intensive care unit nurses, operating room nurses, ward nurses, social workers, public health workers, and hospital volunteers) whom the chairmen believed possessed differing views within each department. We also asked the most active nongovernment patient support organization, the Taiwan Healthcare Reform Foundation, to suggest participants from a variety of patient support groups. Most of the potential participants joined the study or recommended other suitable participants.
Ninety-one people participated in the NGT meetings between 2008 and 2009. We organized these participants into 12 NGT groups according to their occupation: attending physicians, chief residents, medical humanities educators, intensive care unit nurses, operating room nurses, ward nurses, social workers, public health workers, standardized patients, hospital volunteers, medical students, and patient advocates. The demographic data of the participants are shown in Table 1. Our study protocol was reviewed and approved by the National Taiwan University research ethics committee.
We oriented each group to the purpose of the meeting and the procedure that would be followed. The first step was for each participant to write down what he or she considered to be the essential abilities of a professional doctor. The purpose of this exercise was to capture participants' expectations regarding medical professionals. In the second step, participants took turns naming one item from their list at a time without further discussion. This process continued until all participants had expressed all of their ideas. In step three, the participants discussed all items and combined any closely related ideas into a single item. When determinations were not unanimous, the person who initially raised the item could decide whether or not to combine the idea or leave it as a separate item.
In the fourth step, each participant selected five items he or she regarded as most important and voted on these five items using a five-point Likert-type scale, where 5 = most important and 1 = least important. The fifth step was to sum the voting results and rank the items.
After the NGT meetings, the dean of our medical college convened an expert committee to discuss the results of all NGT meetings. The expert committee consisted of the dean, two associate deans, and three senior faculty members involved in curriculum planning. The committee also reviewed well-known published frameworks of medical professionalism, including the Association of American Medical Colleges' Medical School Objectives,29 the ACGME Outcome Project,9 the Physician Charter,6,7 “The duties of a doctor” of the General Medical Council,30 “The Scottish Doctor,”31 CanMEDS,32 and Stern's33 treatise on medical professionalism. The committee constructed a professionalism framework to guide our professionalism curriculum development through consensus meetings. In the meetings, the committees considered the historical and cultural backgrounds of our institution and the core competencies of medical professionalism informed by our NGT process and the literature.
Text analysis of NGT transcript
We recorded and transcribed NGT meetings verbatim. The transcript was 123 pages, containing 113,547 Chinese characters. After the expert committee constructed the framework, we used NVivo 8.0 software (QSR International Pty Ltd.; Doncaster, Victoria, Australia) to conduct a text analysis of the transcripts of the 12 NGT sessions. The purpose of this analysis was to ensure that the expert committee represented the opinions about professionalism attributes nominated by the participants in the consensus framework.
Our process yielded three forms of results: (1) the NGT process rating results, (2) the framework constructed by the expert committee, and (3) the review of the transcript to confirm the consensus framework.
The NGT process voting results
The number of core competencies of medical professionalism agreed on by NGT groups (Table 1) ranged from 5 to 23. Voting results of the top five items of each group are shown in Supplemental Digital Table 1, http://links.lww.com/ACADMED/A57.
The framework constructed by the expert committee
Among the published frameworks of professionalism, the framework proposed by Stern33 influenced our committee most. Serendipitously, Stern's pictorial framework also closely resembles the façade of the NTUCM Medical Humanities Museum—a historical symbol of medical professionalism at our institution. Stern depicts medical professionalism in the shape of a Greek temple, with three foundational steps (clinical competence, communication, and ethics) and four columns (humanism, excellence, accountability, and altruism). After iterative deliberation, the expert committee reached consensus that our visual framework should include “integrity” across the tops of the columns that make up Stern's framework because integrity is the key for integrating the different principles of medical professionalism. Furthermore, the committee added blank columns on the second level of our framework to leave space for medical professionals to fill in their additional personal professional values. Our institutional framework for medical professionalism is shown in Figure 1.
The review of the transcript to confirm the consensus framework
After the expert committee constructed the NTUCM framework for medical professionalism, we reexamined the transcripts of the NGT meetings. We reviewed the top-ranked items to see whether the items nominated by each group (Supplemental Digital Table 1, http://links.lww.com/ACADMED/A57) could be categorized into the eight competencies highlighted in the newly constructed framework (Figure 1). For instance, the visual framework “Ethics” includes confidentiality, medical ethics, and high moral standards. “Humanism” encompasses empathy, respecting lives, and respecting other individuals. “Accountability” includes responsibility, accountability to team members, and responding to societal needs. “Altruism” includes serving others and primacy of patients. “Integrity” includes honesty, frankness, adhering to one's principles, and admitting one's failures.
By analyzing the transcripts of the meetings according to the original wording of the participants, we were able to place most items identified by NGT participants within the NTUCM framework developed by the expert committee. Figure 2 shows the mapping of the NGT results on the NTUCM's framework for professionalism. Four related items identified by NGT participants did not fit neatly into the named steps or pillars: “management of personal time and lifestyle,” raised by teaching chief residents; “self-care,” raised by social workers; “time management” (time for family and recreations), listed by students; and “healthy lifestyle,” raised by patient advocates. Although the relative importance of the eight professional values differed from one group to another, each value was addressed by all groups.
By pooling all the votes and calculating the overall ratings of each professional value, we elucidated the values most emphasized by participants, such as humanism, communication, accountability, and ethics (Figure 3).
Although medical professionalism is a goal which medical educators pursue in earnest, the process of identifying the sources and context of objectives has seldom been explored. Sociologists observing the “professionalism movement” are challenging medical educators to pause and reflect on (1) who determines the concepts and attributes of professionalism and (2) the processes by which these values emerge.16
To carefully address the element of who determines the concepts and attributes of professionalism, we invited more stakeholders than did previous studies to participate in the process of defining professionalism for our institution. In the medical education literature, previous definitions of professionalism derive mainly from doctors,5,6,34 although some studies involved patients,35–37 students,35 and residents.36 Only a few studies included nurses.37 Our study included physicians at different stages of training, various types of allied health professionals, and members of the public who are not patients but have frequent interaction with patients and the medical professionals.
Considering the process by which professionalism values emerge, this method addresses the limitations of previous focus group studies35–37 because NGT has been shown to reduce problems associated with traditional group discussions by limiting the effect of dominating personalities and ensuring the elicitation of all ideas and votes. These features of the NGT are particularly useful in cultural settings, like Taiwan, where seniority and authority are emphasized. Indeed, Cruess et al38 warn of the danger of consensus methodology, noting the tendency to use focus groups among medical educators to promote buy-in. Cruess et al also suggest that the medical profession alone cannot define medical professionalism and posit that such processes require some familiarity with the literature in order to avoid “important omissions or an unbalanced definition.” Our process was devised to avoid these pitfalls both by constructing a basic framework informed by the literature and by including nonmedical participants in the process.
In an earlier focus group study, Wagner et al36 identified patient relationships, knowledge, technical skills, and character virtues as the primary themes of medical professionalism. These items are recognized in our NGT study and parallel the three fundamental steps in the NTUCM professionalism framework. However, humanism and social accountability, which are key components of professionalism in the literature, were not explicitly discussed by Wagner. These items were deemed crucial by our participants, and humanism received significant votes in our NGT groups. This might reflect the advantage of NGT over the usual focus group method.
In addition to the benefits of advancing the methods of generating a general professionalism framework, another strength of this study is to challenge the uncritical adoption of Western professionalism frameworks in non-Western settings. At first glance, our framework shares some similarities with its Western counterparts. Clinical competence, communication, and ethics are the foundational steps on which medical professionalism is built. The four pillars of humanism, excellence, accountability, and altruism are the core—supportive principles to be wisely applied to medical practice. It is possible to reorder the steps and pillars according to perceived importance, but the committee agreed that the items placed on the steps are foundational to learning and practicing medicine and that the items in the pillars represent aspirations for effective professional physicians (Figure 1).
The most striking difference between the NTUCM framework and Stern's framework is the consensus among our expert committee to ensure the addition of “integrity” as the beam capping the four pillars. Whereas Western frameworks based on the Hippocratic tradition stress the primacy of patients, the Confucian tradition of Taiwan emphasizes that one should become a person with integrity in order to serve others. Confucius39 wrote, “The virtuous man, in the world, does not set his mind either for anything, or against anything; what is right he will follow.” Similar to Western philosophies of virtue ethics, Confucians believe that people with integrity will make ethical choices even under temptation and confusion. The expert committee placed the concept of integrity centrally in our framework because the Confucian tradition is more powerful than the Hippocratic tradition in the Taiwanese context. This framing reminds us that the cultivation of integrity would guide us to choose the right path and to harmonize potential conflicts.
Although NTUCM's framework for medical professionalism addressed most of the items identified in the development process, a few items raised by some NGT groups were not easily incorporated. These items did not fit in the category of humanism, which denotes a sincere concern for others, and were instead concerned with the balance between physicians' personal and professional lives. For example, participants listed managing time for family and self, healthy lifestyle, recreation, and self-care. Whereas Western professionalism frameworks emphasize the primacy of patients and separate physicians' professional and personal lives, Confucian cultural traditions support the harmony of these roles.
In Confucian thinking, the position of the self is inseparable from, if not dependent on, one's social roles. Thus, we created a “living framework” that accounts for individual as well as professional values. We designed our professionalism framework intentionally to include empty space, which acknowledges personal responsibility in addition to social responsibility. The presence of flexible space amidst the otherwise structured scheme signifies the reality that a physician's professionalism is both grounded and dynamic—based on core principles defined by society, but also responsive to personal growth over time.
Multiple items categorized into the eight-competency framework align with deep cultural meanings in Taiwan. For example, we categorized the concept of zi zhong (conducting oneself with dignity) into “integrity.” Zi zhong has a long tradition in Chinese culture. In traditional Chinese culture, it is widely accepted that to be self-dignified or self-respecting is one of the first steps toward becoming a Confucian scholar or official. Literature dating back 2,000 years articulates the importance of zi zhong as a virtue of a government official, because of its effect on the well-being of laypeople and the prosperity of the country.40 This concept, also raised by the NGT participants, is deep-rooted in our culture and carries more weight than “integrity” as it is described in existing Western professionalism literature.1–7,33–38 We plan to conduct further research to investigate the complex relationship between existing professionalism frameworks and Confucian values. It would be interesting to conduct comparative studies applying similar methods in other non-Western countries where the influence of Western medicine is less prominent than in Taiwan. To our knowledge, and according to an international working group's discourse analysis,17 there are no studies reporting non-Western models of medical professionalism other than a Japanese study which found a professionalism mini-CEX exercise reliable and valid but added four more culturally relevant items.15
After constructing NTUCM's framework for professionalism, we took several steps to promote the core values of our framework at our institution. Curriculum planners addressed the calling for greater clinical competence and excellence by more carefully integrating these competencies into existing curricular structures. To address humanism and communication, we revised the courses of the first two years substantially, especially courses in liberal arts and medical humanities. As for ethics, accountability, altruism, and integrity, our institutional leaders placed an emphasis on addressing the “hidden curriculum.”41,42 As examples, the institution supported awards for altruism and promoted essay contests surrounding appreciative inquiry.
In concert with these curricular and extracurricular changes, student committees actively promoted professionalism. One example is a student-initiated self-study to examine both formal and informal curricula. That faculty members, support staff, and students readily accepted these measures suggests that our process and resulting framework reflected the values of our stakeholders. In contrast, a previous effort to adopt a Western framework of professionalism at our teaching hospital was not well received by teachers or students. As Cruess et al43 suggest, “when professionalism is taught, it should be related to the different cultures and social contracts, respecting local customs and values.”
A limitation of this study is that we only ran one NGT meeting for each group. Ideally, we would continue holding NGT meetings for each occupational group until the data reached saturation—that is, until no more new attributes were identified by new NGT groups. Another limitation of this study is that the nonmedical participants (medical humanities educator, standardized patient, hospital volunteer, and patient advocate) might be so involved with medical professionals that their views about the ideal doctor might differ from those of the general public, which defines the society's contract with the medical profession. Although our study involved patient advocates who have a deep understanding of the medical needs of the general public, further studies with more NGT participants would address these limitations.
In conclusion, this study challenges the universal applicability of the Western frameworks of medical professionalism and proposes a process to build a professionalism framework that reflects the cultural heritage and the values of local stakeholders. We found it was worthwhile and rewarding for our institution to search for a professionalism framework reflecting our cultural heritage and the values of the stakeholders. Other institutions may adopt the approach described in this report to promote a framework of professionalism that fits their institutional values and traditions.
The authors would like to thank the other expert committee members: Drs. Guan-Tarn Huang, Hong-Shiee Lai, Yung-Chie Lee, and Fu-Chang Tsai. The authors also wish to thank Hui-Wen Chang and Yi-Xuan Li for administrative support, Taiwan Healthcare Reform Foundation and National Taiwan University Hospital chairs for recommending nominal group technique (NGT) participants, and especially all the participants of NGT meetings.
This study was funded by the National Science Council and the Ministry of Education, Taiwan. The funders had no role in study design; in the collection, analysis, and interpretation of the data; in the writing of the manuscript; or in the decision to submit for publication.
The study was approved by the National Taiwan University Hospital research ethics committee.
These results were presented at the Ottawa Conference, Miami, Florida, May, 2010; at the Flexner Report Centennial International Conference, Taipei, Taiwan, November 2010; and at the eighth Asian-Pacific Medical Education Conference, Singapore, January 2011.
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