Even though professionalism is recognized as 1 of the 6 core competencies that residents must achieve during graduate medical education,1–5 many questions regarding the definition, assessment, and demonstration of professionalism remain unanswered. In addition to becoming competent in patient care and medical knowledge, students and residents must become professionals. Furthermore, professionalism is rapidly becoming a key component of state licensure, hospital credentialing, board certification, and maintenance of certification.6–15
To help educators understand what needs to be taught, and how this information should be taught, we decided to assess the attitudes toward and knowledge about professionalism in graduating medical students. This information was then compared and contrasted with the attitudes and knowledge of surgeons in training and practice, to determine what gaps may exist, as the student journeys into the domain of becoming a physician. Such data are critical for the strategic development of educational programming that demonstrates the cognitive, behavioral, ethical, and social components of professionalism.16,17
This project attempts to discern some of the similarities and differences between medical students, who have not yet embarked on their chosen career path, and practicing clinicians, who have experienced first-hand the realities of patient care. Just as medical knowledge and patient care change with new information and technology, professionalism undoubtedly evolves with cultural, environmental, and economic shifts. We hypothesized that students and physicians share a basic understanding of what it means to be a professional, but that certain elements must be learned, as students become physicians, trainees become autonomous providers, and fully trained clinicians pursue life-long educational enrichment.
Physicians have “one” identity, that involves a life committed to service and healing, yet medical trainees, clinicians, and educators are “not the same,” in terms of their experience and exposure to professionalism. Our similarities help to define who we are as doctors, but our differences may help us to carry each other, as we become professionals.
MATERIALS AND METHODS
To determine the attitudes and knowledge about professionalism among health care providers, we administered an anonymous, web-based questionnaire (www.surveymonkey.com, Palo Alto, CA). The survey, which can be found in the Appendix, received an exemption from the Office of Human Research Ethics at the University of North Carolina, as IRB Study 12-0025. The survey was sent to participants 3 times. Incentives to participate included 10 iPod Touches (Apple, Cupertino, CA), which were awarded to subjects by random prize drawing.
The questionnaire was sent to fourth year medical students participating in a capstone course immediately before graduation (n = 160), surgical residents (n = 219), and attending surgeons (n = 99), at a university academic medical center in the Southeastern United States. The capstone course included a 2-hour didactic session, designed by the first author (C.S.H.), that focused on teaching the cognitive, behavioral, ethical, and social components of professionalism.18–31 Students responded to the survey before the course, and the questionnaire was used as a learning tool and starting point for discussion of this competency. Regarding the physicians who answered the questionnaire, the survey was sent to all residents, fellows, and full-time clinical faculty in the following departments: surgery (acute care surgery, burn surgery, surgical oncology, vascular surgery, cardiothoracic surgery, urology, pediatric surgery, transplant surgery, plastic surgery, and gastrointestinal surgery), otolaryngology, orthopedic surgery, obstetrics and gynecology, ophthalmology, and anesthesia.
We compared and contrasted the responses of the medical students with those of the physicians, focusing on demographic information, attitudes toward professionalism, and knowledge about professionalism. Participants were asked to define professionalism, to identify the critical components of professionalism, to cite examples of unprofessional behavior that they personally had observed, to rank the egregiousness of 30 scenarios, and to indicate best practices for teaching and assessing professionalism. Question formats were multiple choice, rank-order, 5-level Likert item, and free-form response. Email addresses were collected from participants who consented to be included in the raffle.
The 2 cohorts were compared using t test for continuous variables and χ2 for categorical data. Statistical significance was assigned to P values less than 0.05.
Compared to the physicians in this survey, medical students were younger (27.8 vs 38.0 years, P < 0.001) and had a higher percentage of women (51.1% vs 36.6%, P < 0.03). The response rate for medical students (134 of 160, or 83.8%) was substantially higher than the response rate for the physicians (93 of 318, or 29.2%) (P < 0.001). 21.9% of medical students reported having a career before medical school, compared to 26.1% of physicians.
Medical students from the fourth year capstone course listed the following areas as future careers, in decreasing order: internal medicine (17.3%), pediatrics (12.8%), family medicine (12.0%), anesthesia (9.8%), obstetrics and gynecology (9.8%), psychiatry (6.0%), medicine/pediatrics (5.3%), emergency medicine (5.3%), orthopedic surgery (3.8%), ophthalmology (3.0%), head and neck surgery (2.3%), general surgery (2.3%), urology (2.3%), radiation oncology (2.3%), radiology (1.5%), neurosurgery (0.8%), plastic surgery (0.8%), neurology (0.8%), dermatology (0.8%), medicine/psychiatry (0.8%), and transitional year (0.8%). None of the medical students reported pursuing a career in physical medicine, pathology, or preventive medicine.
Physicians in our survey reported the following career choices, in decreasing order: general surgery (30.1%), orthopedic surgery (12.9%), plastic surgery (10.8%), urology (9.7%), head and neck surgery (8.6%), thoracic surgery (6.5%), obstetrics and gynecology (5.4%), ophthalmology (4.3%), neurosurgery (4.3%), anesthesia (3.2%), vascular surgery (2.2%), oral-maxillofacial surgery (1.1%), and medicine (1.1%—this physician was completing an internship in surgery).
Definition of Professionalism
Both groups picked “the development of and conformance to a body of ethics” as the defining component of professionalism (medical students, 92.2%; physicians, 94.3%). The next most important component of professionalism was “the ability and willingness to apply knowledge and skill to a greater social good” (medical students, 68.0%; physicians, 72.7%). The 3 categories of “altruism and the engagement in social service,” “the requirement of special education, training, and knowledge,” and “autonomy with the right to self-regulate,” were less important than the two noted above, ranging from rates of 48.9% to 53.9%.
Force-Rank of Core Competencies
In terms of the 6 core competencies, professionalism ranked third in importance for physicians and fourth for students (Fig. 1). Both groups demonstrated a trimodal distribution of the competencies, when asked to force-rank these categories.
Educational Efforts to Teach Professionalism
The overwhelming majority of respondents agreed that professionalism could be taught, learned, and assessed. Students (74.8%) agreed or strongly agreed that “professionalism can be taught,” compared to 78.4% of physicians. Students (83.2%) agreed or strongly agreed that “professionalism can be assessed,” compared to 84.1% of physicians. Students (88.0%) agreed or strongly agreed that “professionalism can be learned,” compared to 92.1% of physicians.
Both groups cited mentoring and modeling, followed by personal experience, as the best methods to teach professionalism, with book club, journal club, and lectures as the least effective methods. Small group discussions, case conferences, and morbidity and mortality conferences were acknowledged as helpful but not cited as the most important methods to teach professionalism, by both groups. Regarding assessment of professionalism, direct observation and 360 degree peer evaluations were noted as the best methods to rate professionalism. Both groups agreed that written tests were the least effective method to assess professionalism, followed by portfolios and journals.
Observation of Unprofessional Behavior
An overwhelming majority of medical students (n = 134) and physicians (n = 93) have observed unprofessional behavior in other health care providers (Fig. 2). When asked to list unprofessional behavior that was directly witnessed, both groups cited “poor anger management” as the most common form of disruptive or unprofessional behavior. However, the 2 groups differed considerably with other types of behaviors that had been observed (Table 1). For example, 73.5% of medical students had witnessed “lack of respect for patient autonomy,” compared to only 48.1% of physicians. “Physical abuse” had been observed by 14.3% of physicians and 1.7% of students; “sexual misconduct” by 11.7% of physicians and 3.4% of students; and “substance abuse” by 23.4% of physicians and 13.7% of students.
Perceptions of Unprofessional Behavior
Both medical students and physicians picked the following scenarios as the most egregious: working while impaired, fraudulent billing, dating a patient, lying on rounds, self-prescribing valium, and sexual harassment, but not in the same order. Least egregious examples were: prescribing antibiotics for a family member, use of a pen with a drug company logo, exceeding work-hour restrictions, receiving honoraria from a speakers’ bureau, and advertising on a billboard. The most and least egregious cases are listed in Tables 2 and 3, with a score of 5 representing the most unprofessional scenario and 1 being the mildest, in terms of disruptive or unprofessional behavior.
Attributes of Professionalism
Physicians and medical students were asked to rank the importance of various attributes associated with professionalism, and integrity/honesty and morality/ethics were selected as the most critical components. The assessment of 10 attributes is listed in Table 4.
Self-Reported Definitions of Professionalism
Participants were asked to define professionalism in 1 sentence. Sample responses from the students include:
“Acting at all times in a manner that your mother would be proud of.”
“Belonging to an organized group that uses specialized knowledge to hold together the highest ethical standards, not only through punitive forms of correction, but more importantly through mentorship, to reach the highest levels of virtue, so that this particular knowledge can be of the greatest service to patients and society.”
Physicians expressed similar comments:
“Doing the right thing—always.”
“Professionalism is the end result of a personal commitment to a code of ethics and conduct, based on honesty, integrity, and self-regulation; with dedication to the maintenance of specialized skills that are exercised for the benefit and well-being of others; combined with a life-long strategy for continuous learning in the domains of intellectual curiosity, altruism, situational awareness, and self-control; to the end that these qualities and characteristics may be modeled, communicated and passed on to others, who seek to follow the patterns that define a particular profession.”
In this paper, we demonstrate that medical students and surgeons in training and practice have similar attitudes about professionalism, but differ in their observations of unprofessional behavior. Despite the differences in age and sex—students are younger and more likely to be female—both groups agree that professionalism is a legitimate competency that can be assessed, taught, and learned, most effectively through direct interactions between the educator, the trainee, and the patient. Furthermore, students and physicians generally agree about what constitutes good and bad behavior, although some of these behaviors may be perceived with differing degrees of concern. Although medical students and surgeons are “one” in their attitudes about professionalism, they are “not the same” in their experiences regarding this core competency.
Previous work from our group has focused on developing an educational curriculum that addresses professionalism in surgery.32–35 We initially created a course for plastic surgery residents and faculty, that was later modified for all acting interns in surgery. Based upon the success of these endeavors, we reached out to all of our graduating medical students and now present a 2-hour seminar, during the final capstone course, held immediately before graduation.
From this experience, we recommend the following principles:
- Professionalism involves multiple key elements: altruistic engagement in social service; the requirement of special education, knowledge, and training; the ability and willingness to apply this knowledge and skill to the greater good of society; development of and conformance to a body of ethics; and autonomy with the right to self-regulate18
- Professionalism therefore represents a privileged contract between 3 parties: the physician, the patient, and society19
- Professionalism includes concrete components that need to be taught and assessed: behavioral, cognitive, social, and ethical34
- Professionalism should be modeled from the top; therefore leaders must learn how to be professionals, by acting like professionals25–27
- Professionalism should begin on or before the first day of medical school and remain a educational topic for one’s entire career36–40
- Professionalism requires that mentors inspire, challenge, and question, not only their students, but also themselves, to facilitate experiential learning32
- Although knowledge and skills are essential to understanding professionalism, managing behavior is paramount to a successful career, lowering malpractice risk, and maintaining personal health
- Because unprofessional and disruptive behaviors are so varied in their presentation, understanding causation is often difficult. While prevention through education should remain an important goal of life-long learning, institutional resources must be made available to determine if remediation is possible and what type of rehabilitation is indicated.
Several observations from this study are particularly interesting. When asked to rate the potential professional misconduct of 30 clinical scenarios, both cohorts—medical students and physicians (mostly surgeons)—closely agreed upon what constituted the 10 worst behaviors and 10 least egregious behaviors, albeit in slightly different order. Students know, through intuition, early modeling, or perhaps preformed ethical principles, what behavior is unprofessional and constitutes misconduct. However, when new technologies and new social constructs are introduced, such as Facebook or Twitter, subtle differences between students and physicians emerge. What may be offensive to a senior attending surgeon (such as compromising pictures posted on Snapchat or Instagram) may serve as humor for younger trainees, who have different social and professional boundaries than their older colleagues.
Another fascinating finding is that advertising, once absolutely banned by the American Medical Association as unethical and unprofessional, is completely accepted by both students and clinicians, in our survey. Thus, professional standards are partly in flux, subject to cultural and social forces, rather than permanently fixed as universal ideals. What is clear, however, is that at a given time, for a given place, for a given set of professionals, the standards that define the profession—medicine, theology, law—are absolutely essential. Because environmental, economic, and logistical forces may shape the lens of society and bend the image of our contract with society, professionals must continue life-long learning. The professionalism standards of tomorrow will be similar, but different, from what we perceive today.
One area in medicine that is quickly evolving is the relationship between clinicians, commercial enterprises, and the health care industrial complex. Both students and physicians sense that boundaries should exist between these competing entities, but these lines have not been fully delineated. A surgeon who develops a patent for a device that is used in her practice, who consults for pharmaceutical companies, or who markets a new entrepreneurial endeavor clearly holds significant power and leverage over patients, but 2 questions emerge: to what extent does this surgeon have a conflict of interest, and how should this conflict be managed?40 Although the majority of the respondents to our survey did not believe that such relationships were necessarily unethical or egregious, such behavior may still have negative effects on one’s practice or career, due to institutionally-defined policies or local standards. Speaking for a pharmaceutical company about a new drug may be legal and help educate community surgeons, but such behavior may not be permitted if the physician works for a university. We all have conflicts of interest that we must manage, but how well we manage those conflicts and how accurately we disclose those conflicts determines our level of professionalism.
One disturbing observation from our report is that severe lapses in professionalism continue to occur, in students, clinicians, and administrators.
Sexual misconduct, boundary breaches, fraud, substance abuse, bullying, discrimination, and even physical abuse persist. Although our medical students reported lower observation rates than our clinicians, we strongly suspect that the higher rates observed by physicians are related directly to time spent in practice. The senior authors repeatedly admonish medical students and residents that behavioral misconduct, not lack of patient care skills or medical knowledge, is often what derails physicians’ careers and results in sanctions, forfeiture of licensure, and failure to obtain or maintain certification.
The primary limitation of this study is that we compared 2 different cohorts, which undoubtedly have differences other than gender or age to account for varying attitudes toward professionalism. The clinician group was composed of mostly surgeons and surgical subspecialists and also included both residents and attending physicians. The student group involved graduating medical students, at the completion of their medical education, immediately before the start of their graduate medical education. Therefore, comparisons between the 2 cohorts should be done with the knowledge that each group was quite heterogeneous. Following a specific group longitudinally would be an ideal next step to assess the development of professionalism as a core competency.
Another limitation to this study, in addition to the confounding variables of age, gender, and length of time in practice, was the uneven response rate between the 2 cohorts (medical students, 83.8%; surgeons, 29.2%). Although participation by the medical students was not required to pass their 4th year capstone course, the survey was used as a learning tool that directly impacted the curriculum, whereas participation by the surgeons was not linked to any educational program, except for this project. The incentive of receiving an iPod Touch may also have been more meaningful to the younger cohort. In any event, the low response rate of the surgeons could easily introduce sampling error and bias the outcomes, by including data largely from surgeons who had strong opinions about professionalism, compared to those who were less interested.
As students and practitioners of medicine, all of our participants belong to a spectrum of providers who aspire to be professionals. Education, through modeling and mentoring, can be combined with pre-formed ideals of ethical behaviors, to improve our standards for professionalism and allow these standards to evolve. Students and clinicians may not be at the same level of professional and personal development, but many of their attitudes toward professionalism are the same. In order to belong to one profession—medicine—we need to carry each other.
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Web Based Survey Questions
Professionalism in Surgery and Anesthesia
- (1) This questionnaire received and exemption from the Office of Human Research Ethics at UNC, IRB Study 12-0025. The results of this survey may be presented at national meetings and published in peer-reviewed journals. Your answers will remain anonymous and will not be linked to your email address or to any other identifying information. You will have the opportunity to enter into a raffle for an iPod touch. To enter the raffle you must provide your email address, which will be used solely for winner notification and will not, in any way, be linked to your answers on the survey. Do you provide consent and agree to participate in this study?
- (2) What is your level of training of expertise?
- (a) Acting intern in surgery or anesthesia
- (b) Resident
- (c) Fellow
- (d) Attending physician
- (e) Non-physician provider
- (f) Administrator
- (g) MS IV Capstone Course
- (3) Indicate your field of training or practice.
- (a) General surgery
- (b) Neurosurgery
- (c) Urology
- (d) Vascular surgery
- (e) Thoracic surgery
- (f) Plastic surgery
- (g) Head and neck surgery
- (h) Oral-maxillofacial surgery
- (i) Ophthalmology
- (j) Obstetrics and gynecology
- (k) Anesthesia
- (l) Pediatrics
- (m) Medicine
- (n) Family medicine
- (o) Physical medicine and rehabilitation
- (p) Neurology
- (q) Radiology
- (r) Radiation oncology
- (s) Pathology
- (t) Dermatology
- (u) Emergency medicine
- (v) Psychiatry
- (w) Medicine and pediatrics
- (x) Medicine and psychiatry
- (y) Preventive medicine
- (z) Transitional year
- (aa) Other
- (bb) Undecided
- (cc) Business and administration
- (4) What is your age?
- (5) What is your gender? (F/M)
- (6) Did you have a career before entering medical/graduate school? (If not a clinician, please skip.) (Y/N)
- (7) Using currently accepted definitions of professionalism, please select from the following options the essential characteristics of professionalism. Pick as many components as you think would apply.
- (a) Altruism: the engagement in social service
- (b) The requirement of special education, training and a high degree of knowledge
- (c) The ability and willingness to apply knowledge and skill to a greater societal good
- (d) Autonomy: the right to self-regulate
- (e) The development of and conformance to a body of ethics
- (8) Graduate medical education uses the following 6 competencies to assess performance. Please rank-order their importance, assigning a number from 1 to 6 and use that number only once. 1 is most important and 6 is least important.
- (a) Medical knowledge
- (b) Clinical skills
- (c) Professionalism
- (d) Systems-based practice
- (e) Practice-based learning
- (f) Communication
- (9) Please indicate if you agree with the statement; “Professionalism can be taught”.
- (a) Strongly agree
- (b) Agree
- (c) Neutral
- (d) Disagree
- (e) Strongly disagree
- (10) Professionalism is taught well at UNC.
- (a) Strongly agree
- (b) Agree
- (c) Neutral
- (d) Disagree
- (e) Strongly disagree
- (11) Professionalism can be assessed
- (a) Strongly agree
- (b) Agree
- (c) Neutral
- (d) Disagree
- (e) Strongly disagree
- (12) Professionalism can be learned
- (a) Strongly agree
- (b) Agree
- (c) Neutral
- (d) Disagree
- (e) Strongly disagree
- (13) What are the obstacles to teaching professionalism? Please check all that apply.
- (a) Professionalism cannot be taught
- (b) There are not enough mentors
- (c) Not a priority in medical school curriculum
- (d) Teachers do not have enough background or training in professionalism
- (e) Not enough time in medical school curriculum
- (14) Please rank the following educational methods used to teach professionalism, using a Likert scale of 1 to 5, with 5 being the most effective and 1 the least effective.
- (a) Mentoring
- (b) Modeling others
- (c) Personal experience
- (d) Case conference
- (e) Morbidity and mortality
- (f) Small group discussion
- (g) Lectures
- (h) Journal club
- (i) Book club
- (15) Please rank the following examination methods used to assess professionalism, using a Likert scale of 1 to 5, with 5 being the most effective and 1 the least effective.
- (a) Written test
- (b) Oral examination
- (c) OSCEs (Objective Structured Clinical Exam)
- (d) Direct observation
- (e) Simulation
- (f) Portfolios and journals
- (g) 360 degree and peer evaluations
- (16) Have you observed unprofessional behavior in:
- (a) Medical students
- (b) Residents
- (c) Fellows
- (d) attending physicians
- (e) nonphysician providers
- (f) hospital administrators
- (17) If you have personally witnessed unprofessional behavior in the setting of health care, what types of behavior have you seen? Please select all types that apply
- (a) Bullying and/or intimidation
- (b) Substance abuse
- (c) Disruptive behavior
- (d) Physical abuse
- (e) Dishonesty
- (f) Personal boundary issues
- (g) Confidentiality violations
- (h) Fraud and/or deceit
- (i) Sexual misconduct
- (j) Discrimination
- (k) Poor anger management
- (l) Lack of respect for patient autonomy
- (18) Rank the following scenarios in terms of unprofessional behavior, using a Likert scale of 1 to 5, with 5 being the most unprofessional/egregious behavior and 1 being the least. Please do your best-there are no right answers.
- (a) An attending throws a surgical instrument in the operating room (OR)
- (b) A medical student vomits a Health Insurance Portability and Accountability Act violation by looking at the medical record of a celebrity, whose care does not involve the student
- (c) A resident refuses to see a consult in the emergency room
- (d) A resident makes a sexual advance on a medical student
- (e) An attending says a racist “joke”
- (f) A resident arrives late to work, with alcohol clearly on his or her breath
- (g) An attending is chronically late to time-outs in the OR
- (h) An attending demeans a resident during a morbidity and mortality conference
- (i) A medical student lies about patient data during teaching rounds
- (j) A resident fails to perform adequate sign out of patients to the on call team
- (k) A resident exceeds work hour restrictions by logging too many hours in one week
- (l) A surgeon owns stock in a biotech company whose device he or she uses routinely in the OR
- (m) A medical student uses a pen with a drug company logo on its side
- (n) A resident uses a textbook purchased by a drug company
- (o) A surgeon receives an honorarium from a drug company for speaking at a private dinner about a new pharmaceutical agent
- (p) A surgeon does not disclose to the Dean’s office that he or she serves on a consulting board for a biotech device company
- (q) A plastic surgeon offers a free breast augmentation at a charity raffle, without having met any of the prospective patients
- (r) A plastic surgeon shows before and after pictures of patients not in his or her practice, but does not inform prospective patients
- (s) A surgeon advertises with a billboard on the interstate highway
- (t) A surgeon splits fees with a referring internist, to increase the number or patients in his or her practice
- (u) A surgeon bills Medicare for a procedure in which he or she was immediately available, but not present for the key components
- (v) A surgeon bills Medicare for a procedure when he or she was out of town on a mission trip
- (w) A surgeon who has a complication becomes distraught and cries in front of a patient
- (x) A resident posts pictures on Facebook, showing that resident holding a beer bong at a late-night party
- (y) A faculty member uses Twitter to engage in a sexually explicit conversation with an operating room nurse
- (z) A physician prescribes antibiotics for his or her child, who has an ear infection
- (aa) An anesthesiologist discovers that a surgeon has a substance abuse problem with narcotics and does not report this to anyone
- (bb) A physician prescribes valium for himself or herself
- (cc) A physician begins to date a patient who is still under the medical care of that doctor
- (dd) A physician begins to date a former patient, who is not receiving care from that doctor anymore
- (19) Rank the following attributes of professionalism, in terms of importance, using a Likert scale from 1 to 5, with 5 being the most important and 1 being the least important:
- (a) commitment
- (b) competence
- (c) altruism
- (d) morality and ethics
- (e) integrity and honesty
- (f) autonomy
- (g) self-regulation
- (h) responsibility to society
- (i) responsibilities to the profession
- (j) teamwork
- (20) What is your definition of professionalism? Please limit your answer to one sentence.