Abstract: The teaching of professionalism, a key aspect of medical competence that regulates physician’s behavior towards patients, colleagues, society, and self, should be included in the curriculum of every training program. Studies suggest a variety of formats to teach and evaluate professionalism in residents, being role modeling, reflection, case discussions, and 360-degree assessments the most commonly used. However, little is published about the need to train faculty for teaching and evaluating professionalism, or how to improve institutional culture, so that principles that are indicated to teach in theory are also fulfilled in practice.
The demonstration of the acquisition of professionalism as an aspect of professional competence has taken on parallel importance in the last few decades to that of theoretical and practical medical knowledge, patient care or communication skills. Organizations at a global level include Professionalism in their conceptual frameworks for postgraduate training. The Royal College of Physicians and Surgeons of Canada, in its CanMEDS roles, defines the Professional role as the commitment of physicians to the health and well-being of patients and society through ethical practice, high standards of personal behavior, accountability towards the profession and the society, physician-led regulation, and maintenance of personal health (1). The Accreditation Council for Graduate Medical Education (ACGME), in the United States, defines that residents must demonstrate commitment in carrying out their professional responsibilities, adherence to ethical principles, and sensitivity to diverse populations of patients in gender, age, culture, race, religion, disabilities, and sexual orientation, specifying that residents are expected to demonstrate compassion, integrity, and respect for others, and responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; and accountability to patients, society and the profession (2).
Teaching this competency should then be included in post-graduate training programs. The World Federation for Medical Education indicates in its basic Global Standards for Quality Improvement that those responsible for training programs (“programme providers”) must include professionalism training in the education of physicians, defining professionalism as the knowledge, skills, attitudes and behaviors of individual doctors, that are expected by patients and the community during the practice of the profession. These behaviors include, among others, skills of continuous learning and maintenance of competence, ethical behavior, integrity, honesty, altruism, empathy, service to others, justice and respect (3).
A number of articles provide recommendations about how to teach professionalism in the health sciences. In a systematic review for the Best Evidence Medical Education project, Birden and colleagues analyzed forty-three studies and concluded that professionalism is learned more effectively by the influence on students of clinicians they meet in the course of their education (role models), than through didactic lectures; other elements that are considered effective are personal reflections, especially when guided by a teacher (4). Other strategies described in use are writing of a critical incident report (5), vignettes describing professionalism dilemmas (6-8), courses (9-11), teaching in clinical practice (12), books (13), and online courses (14).
A few tools for assessing the acquisition of professionalism by residents have also been published. The Ophthalmology Milestone Project, an initiative of the ACGME and the American Board of Ophthalmology, recommends the use of 360-degree global assessments [the International Council of Ophthalmology (ICO) developed, validated and published this instrument specifically for ophthalmology and for global use (15)], ophthalmic clinical evaluation exercises (OCEX) (16,17), portfolios and chart reviews (18). Other instruments have been developed in non-Western cultures, which consider different items and/or approaches to assess professionalism in residents, given the cultural influence, for example, of Confucianism in Korea (19) and the Bushido value system in Japan, based on Buddhism and Shintoism in addition to Confucianism. Moreover, the word “professionalism” does not exist in many Asian languages, since this term reflects a Western concept (20).
The example of professionalism that teachers model to students, who in turn copy attitudes, values, and behaviors from these role models, is a recurrent theme in several research projects. Unfortunately, role modeling can be a double-edged sword: good and not so good values and behaviors are modeled abreast. In a survey of 665 medical students conducted by Feudtner, Christakis and Christakis, for example, 98% of students reported hearing derogatory comments from teachers about patients, and 61% had witnessed what they considered unethical behavior (21). In another survey of 365 residents, Reynolds, White and Martindale reported that 93% of residents declared being influenced by positive role models, and more than 58% reported that their perception of the importance of professionalism was influenced when the teacher had not modelled professionalism; in addition, residents reported that only 25% of their teachers modelled professionalism all the time (22). In a survey to 208 Pathology residents, between 52% and 73% of the residents reported having observed non-professional behaviors in their teachers (23).
Institutional culture, as Cruess highlights, is key in the transmission of the values that define professionalism, since it provides congruence between what is taught through the declared curriculum (the “official” material in the declaration of the institutional mission) and what students learn through the hidden or informal curriculum (the interaction between teachers and students, role models of all levels, and other factors stemming from the structure and culture of the organization) (24). The influence of this institutional culture, like that of role modelling, can be extremely positive or negative, depending on the values of those who teach and those who learn.
If it is imperative to include teaching and the evaluation of professionalism in the curriculum, it is as well compulsory to train teachers for this task.
If role modeling, reflective skills and institutional culture are the means through which this competence is acquired by residents, teachers should be trained in how to teach and model professionalism, as well as they should have a clear concept about the behaviors needed to teach this competence properly. In general, training of teachers includes instruction in didactic skills to teach technical competencies or those related to patient care (for example, teaching how to diagnose or treat a disease, or how to present a lecture effectively), or to evaluate the acquisition of medical knowledge (for example, how to create questions for a written exam), but it is less frequent to train faculty on how to teach explicitly to be ethical and accountable (25), or to emphasize the importance of being a good role model (24), or of recognizing a lapse in professionalism and declaring the intention of not repeating the behavior in the future. As an example, in a survey of 24 program directors by Heard et al., the majority reported needing assistance for both teaching and evaluating this competence (26).
The ICO Curriculum for Educators includes teaching of professionalism among the teaching methods that educators should acquire (27). Also, during the ICO courses for program directors and faculty, practical examples of how to teach and evaluate this competence are provided.
There are several examples in the literature of faculty development programs on how to teach professionalism. The first one, published by Steinert et al., describes an extensive, systematic and meticulous process to train teachers in the teaching and evaluation of this competence in students and residents. Part of this process consisted of workshops for program directors and teachers, highlighting the importance of teaching professionalism and improving its teaching through the transmission of content, discussion of teaching strategies, and the development of an action plan for each department. As a result, they were able to increase faculty commitment for this task (25).
Al-Eraky et al. describe a program consisting of an orientation workshop, with short lectures and interactive discussion on different topics related to professionalism, creation of vignettes describing real scenarios of conflicts of interest between doctors, patients and colleagues, and the presentation and discussion of these vignettes with the students, as well as a guide of questions to help reflection (28). Bursch et al. describe a workshop where participants, led by two psychologists and two psychiatrists, discussed examples of challenges or possible failures in professionalism experienced in the institution that they personally observed, transformed into confidential scenarios, using audience response systems to respond anonymously, and discussions in small groups. The anonymity in the provision of examples as well as in the answers with the audience response system allowed participants to express their opinions freely (29).
Lu et al. describe the use of an instrument, the Objective Structured Teaching Exercise (OSTE), a series of videotaped scenarios and two performance rubrics, to train faculty in the teaching of professionalism and ethics in clinical settings. They found a significant increase in teachers’ confidence in their understanding of ethical/professional virtues of others in the medical profession, and in their ability to communicate concerns related to the professionalism of their students, to handle problems related to professionalism in which students were involved, and to approach their colleagues to discuss issues concerning their professional/ethical behaviors (30).
Goldstein et al. describe a program consisting of workshops and meetings with teachers on how to facilitate sessions with students to discuss professionalism, lead case discussions, debrief ethical cases, provide personalized mentoring through clinical tutorials, give formative and summative feedback, and teach about cultural diversity. They also explain their experience implementing a new curriculum with the aim of achieving an “ecology of professionalism”, that is, to bring attention to professionalism at all levels of the institution (31). Also with the aim of improving the institutional culture, Humphrey et al. describe a program that includes participants from all university levels in the development of workshops (for example, for the discussion with residents of relationships with the industry and the referral of patients) and evaluations (for example, from patients to their resident physicians) (32).
Beyond any initiative for the “formal” teaching of professionalism, the awareness of teachers about the role and behaviors they model in daily activities, in their relationships with students, colleagues and patients, in the management of their conflicts of interest, and finally, in their permanent effort (or the lack of it) to improve these attitudes and behaviors, should be a key aspect of the daily conversation and evaluation of any training program.
Given that any teaching intervention requires confirming if learning has occurred, the effectiveness of faculty development initiatives for teaching professionalism must also be evaluated. There is little published about the assessment of teachers both in their performance in professionalism and in the way they teach or model it to their students.
Gillespie et al. suggest that observations of the professional behavior of faculty and staff is mandatory (33). A 360-degree evaluation that includes the opinion of students and residents, as well as that of peers, chairs or deans, would be useful in this process.
In the aforementioned study, Lu describes the use of OSTE to evaluate teachers while performing through different scenarios, which were recorded and evaluated by another senior teacher, to then receive debriefing and reflect on their responses (30). The work of Steinert et al., also mentioned above, describes the evaluation of their professionalism training program by asking teachers for feedback on the use of what has been learned in the program (25). However, the evaluation of professionalism should be contextual (13); given the complexity of this competence, it is not enough to ask the teacher about their own professionalism. Professionalism should be evaluated in context, on multiple occasions and by a variety of evaluators.
The most difficult aspect of teaching and evaluating professionalism is possibly at the level of institutional structures. Of course, almost universally, medical institutions place ethics and professionalism in their declared missions and values in a prominent place. But on occasions the actions of both institutional members and/or their authorities are not consistent with what they declare in theory. It is possible to find, to varying degrees, examples of conflicts of interest, abuse of power, inequality or even harassment, which are not always adequately acknowledged, solved or eradicated, becoming models of behavior accepted and transmitted vertically and transversely, damaging the quality of life and eroding the moral values of those working at the institution, those who are trained in it, and ultimately having an impact on the patients they serve.
Clear rules regarding desirable and acceptable professional behaviors, participation of all members of the institution in understanding, disseminating and evaluating the scope of these behaviors, and the conscientious self- and external evaluation of the institution regarding compliance with these rules are just some of the initiatives that could be carried out, so that formal and hidden curriculum are aligned as much as possible.
If teaching professionalism to residents is considered a current and necessary challenge, the training of trainers becomes a key strategy, so that training in a competency that is taught fundamentally through example is carried out in the most effective and adequate way possible. Raising awareness among teachers about the importance of the role they model with their day-to-day behaviors, openly discussing problems that arise with individual or institutional professional lapses, reflecting on how to improve these behaviors in the future, are some of the spaces that must be explicitly included in training programs. Programs should allot these activities the time they need, according to their critical importance; failure to do so demonstrates, implicitly, that the theoretical significance that is given to professionalism in definitions and declarations of intent is not so in practice.
The Argentinean cardiovascular surgeon René Favaloro said, four decades ago: “It must be understood that we are all educators. Every act of our daily life has implications, sometimes significant. Let’s try to teach by example.” We could add “and let’s do our best to make sure that this example is in accordance with the principles of medical ethics and the norms of our medical profession”.
