Teaching and assessment of student attitudes towards professionalism in medicine

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Teaching and assessment of student attitudes
towards professionalism in medicine

• Vikram Jha
• Senior Lecturer in Medical Education
• University of Leeds
• Acknowledgement www.cartoonstock.com

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Profession

• The occupation which one professes to be skilled
  in or to follow-
• A vocation in which professional body of
  knowledge is used in its application to the
  affairs of others or in the practice of an art
  founded upon it
• In a wider sense any calling or occupation by
  which a person habitually earns his/her living

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So is there a difference?

• Some professions require intellectual training
  and acquisition of specialised knowledge
• Work is pursued primarily for others
• Success is measured by more than financial return
• Brandeis LD. Business-A profession. Boston, MA
  Small, Maynard, 1914

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History of Medical Professionalism

• Early literature (1910-1940) favourable-faith in
  virtue, morality, service commitment
• 1960-1970-less favourable-scepticism regarding
  altruism, self-serving, misuse of power
• Post 1980-more favourable-more critical of
  state/services
• Recent high profile cases-Shipman, Bristol

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Sociology and medicine

• Dominance of medicine is decreasing
• Proletarianization has decreased status and
  economy-we need to sell our services
• Deprofessionalisation has occurred (moral)
• Corporatisation and bureaucratization are trends

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Ethics and medicine

• Concept of healer
• Trust
• Patient-physician relationship
• Fiduciary relationship-for the good
• Beneficence

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Dilemma

• Dual role-healer and professional
• Healer (constant)-Hippocratic oath
• Professional (changing)-Business
• Change in societal expectations

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Business versus Professional values

• The practice of medicine is not a business and
  can never be oneOur fellow creatures cannot be
  dealt with as man deals in corn or coal.
  (William Osler 1932)
• Osler W. On the educational value of the medical
  society. In Aequanimitas, with
• other addresses to medical students, nurses and
  practitioners of medicine. 3rd Ed.
• Philadelphia, PA, 1932 329-45

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Current emphasis on medical professionalism

• More complaints against physicians relate
• to unprofessional conduct than lack of
• knowledge or poor technical skills (Ginsburg et
  al 2000)
• Ginsburg S et al Context, conflict and
  resolution A new conceptual
• framework for evaluating professionalism.
  Academic Medicine, 75 (10)
• Suppl 2000

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• Problematic behaviour in school
• associated with disciplinary action
• (Papadakis et al 2004)
• Papadakis MA, Hodgson CS, Teherani et al.
  Unprofessional behaviour in
• medical school is associated with subsequent
  disciplinary action by a State
• Medical Board. Academic Medicine 2004 79 (3)
  244-249

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• Difficulty with defining and measuring
• professionalism is well recognised
• (Baldwin and Bunch 2000)
• Baldwin DC Jr, Bunch WH. Moral reasoning,
  professionalism, and the
• teaching of ethics to orthopaedic surgeons.
  Clinical Orthopaedics and
• Related Research 2000 378 97-103.

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What is medical professionalism?

• Medical Professionalism in the New Millennium
• A Physician Charter (ABIMF, ACP-ASIMF, EFIM
• 2002)
• Principles
• Primacy of patient welfare
• Patient autonomy
• Social justice
• ABIM Foundation, ACP-ASIM Foundation and European
  Federation of Internal Medicine. Medical
  Professionalism in the new millennium a
  physician charter. Annals of Internal Medicine
  2002 136 243-6

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Duties of a Doctor (GMC2001)

• Attributes
• Polite, honest, trustworthy, unprejudiced,
  respectful
• Skills
• Communication, technical
• Behaviour/attitudes
• Confidentiality, error reporting, not abusing
• position as doctor

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Normative definition of professionalism (Swick
2000)

• Subordination of own interests to interests of
• others
• Adherence to high ethical and moral standards
• Respond to social needs
• Core humanistic values
• Accountability
• Excellence
• Commitment to scholarship
• Reflection
• Swick HM. Towards a normative definition of
  Medical Professionalism.
• Academic Medicine 2000 75 (6) 612-616

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Problems

• No guidance from GMC
• Formalisation of teaching and assessment
• enhances perceived importance
• Nebulous terms cannot be operationalised
• Context, conflict and resolution (Ginsburg
• et al 2000)
• Ginsburg S et al Context, conflict and
  resolution A new conceptual
• framework for evaluating professionalism.
  Academic Medicine, 75 (10)
• Suppl 2000

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Attitudes or behaviour

• Attitude-disposition to respond favourably or not
  to something
• Inaccessible to direct observation
• Inferred from measurable responses
• (Ajzen 1996)

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Resonses to attitudes

• Cognitive-beliefs
• Affective-feelings
• Conative-behaviour

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Attitudes and behaviour

• Behaviour influenced by attitudes
• Aggregation theory (Fishbein and Ajzen 1974)
• Global attitudes better at predciting aggregates
  of behaviour or multiple behaviour over wide
  range of contexts
• Theory of planned behaviour

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Views on professionalism

• 7 main themes identified
• Theme includes number of aspects of
• professionalism grouped together
• Idea of more global and broader concepts of
• professionalism than individual attributes and
• behaviours
• Jha V, Bekker HL, Duffy SRG, Roberts TE.
  Perceptions of professionalism in medicine a
  qualitative study. Medical Education 2006 40
  1027-1036

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Pause to think

• Would you send your daughter to see a
• gynaecologist who is known to download
• pornography?

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Views on professionalism

• Easy to state attribute/behaviour but
• difficult to conceptualise
• Largely contextual
• Sometimes grey
• Hierarchy of professionalism

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Compliance to value system

• We were talking about attributes for a Dean and
  there was discussion about whether you wanted
  somebody who could lie well and blithely or
  somebody who inevitably had to blurt out the
  truth.

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Patient access
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Physician-patient relationship
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Demeanour

• The gynaecologist came in wearing
• his hunting gear, slapping the side of
• his breeches with his riding crop and
• extremely loud and arrogant.

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Management

• Personal and collective
• Change from healer to professional

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Personal awareness

• I think people are entitled to have
• prejudices- I think it would be hard to
• find a single person in the world who
• doesn't have some prejudice of one sort
• or another.

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Motivation

• Altruism is difficult, in the American
• literature they emphasise altruism
• and I'm not sure whether this is
• American hype.

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What is professionalism?

• Core aspects-compliance to value system
• Others not as generic
• Proto-professionalism (Hilton)-
• Phronesis-practical wisdom-when to break rules

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Professionalism endangered

• Expert professionalism versus social-trustee
  professionalism (Swick 2000)
• Professional autonomy versus external review
• Medical culture versus business/political culture
• Swick HM. Towards a normative definition of
  Medical Professionalism.
• Academic Medicine 2000 75 (6) 612-616

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Teaching professionalism

• Teaching of professional values occurs most
• often in an informal setting, such as whilst
• having dinner or working together on call rather
• than in more formal settings such as lectures or
• attending rounds (Stern 1998)
• Stern DT. In search of the informal curriculum
  when and where
• professional values are taught. Academic Medicine
  1998 73 (10
• suppl) S28-30.

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Teaching of professionalism

• Identify aspects in curriculum devoted to
  professionalism
• Reinforce this in postgraduate and CME
• Concept that to be a professional is not a right
  but a privilege
• Separate but linked concepts of physician as
  healer and as professional (for delivery of
  service)

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Teaching of professionalism

• Define professionalism and components
• Professionalism is an ideal to be pursued with
  inherent moral value
• Professionalism essential to maintain trust of
  patients
• Knowledge of codes of ethics governing conduct of
  both healer and professional

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Teaching of professionalism

• Nature and limitations of autonomy-individual and
  collective
• Relevant material drawn from sociology,
  philosophy, economics related to professionalism
• Link between professional status and obligations
  to society that must be fulfilled to maintain
  public trust

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Methods of teaching professionalism

• Courses-moral reasoning, physician-patient
  communication, medical ethics, law
• Innovative teaching methods-experiential,
  reflective, self-directed learning. PBL
• Student and teacher support and guidance

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Assessment of professionalism

• Lynch (2004) systematic review
• 191 articles with 88 assessment descriptions in
• 12 categories
• Ethicsaffective/cognitive/behavioural/environment
  al
• Personal characteristics-affective
• Comprehensive professionalism-Cognitive/behavioura
  l/environmental
• Diversity-cognitive/behavioural/environmental
• Lynch DC et al Assessing professionalism a
  review of the literature. Medical Teacher, 26
  (4), 2004, 366-373

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Systematic review of assessmentof attitudes
towardsprofessionalismJha V, Bekker HL, Duffy
SRG, Roberts TE. A systematic review of studies
assessing and facilitating attitudes towards
professionalism in medicine-in press

• 97 articles in all
• 14-professionalism in general
• 31-ethical issues
• 12-academic integrity

• 7-personal values
• 22-acceptable behaviour (pt-phy relations)
• 9-cultural issues
• 1-attire

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Types of measures

• Attitude scales-44
• Response to vignettes-23
• Questionnaires-13
• Combinations-9
• Others-interviews,essays-8

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Problems with measures

• Few measured attitudes towards professionalism in
  general
• Details of derivation of items
• Only 15 measured attitudes longitudinally
• 38 reported both reliability and validity
• No theory underpinning measures

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Interventions to promote professionalism

• 17 articles
• Courses-Ethics course, cultural issues
• Individual teaching sessions-appropriateness of
  sexual contact
• Curriculum-socio-cultural medicine program
• 3 showed no effect
• No long term effect

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Theory of planned behaviour (Ajzen 1991)
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Questionnaire

• TPB framework
• Items from qualitative study on views on
  professionalism
• 27 professional behaviours on 4 themes
• 243 items
• 400 students
• Jha V, Bekker HL, Roberts TE. A measure of
  medical students attitudes towards
  professionalism. Unpublished data

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Compliance to values

• Being economical with truth sometimes when
  talking to patients
• Reporting colleagues for lacking clinical skills
• Talk about patients without using their names
• Report friend for cheating
• Using tissue for research without consent
• Disclose diagnosis to relative
• Think less of colleague for drinking on call
• Have intimate relations with juniors

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Patient-physician relationship

• Be available to patients all hours of day
• Choose treatment options to offer
• Engage with broader community
• Put patient needs before own
• Accept patient choice even when disagree
• Make comments about appearance of anesthetised
  patient

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Management

• Contradict colleagues in front of patients
• Give all team members same respect
• Act superior in front of patients

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Personal awareness

• Admit limitation of knowledge
• Change what they say depending on patient's job
• Dress smartly
• Ask for help from colleagues
• Audit performance
• Tell sexist jokes

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Central components of TPB

• Behaviour-not included
• Attitude-direct
• Behavioural intentions
• Behavioural beliefs-beliefs and outcomes
• Subjective norms-beliefs and motivation to comply
• Perceived behavioural control-beliefs and
  perceived power
• Past behaviour

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Psychometric properties

• Good correlation between TPB variables
• Attitudes and subjective norms strongest
  predictors
• Strong link with past behaviour
• Stability of attitudes over 5 years
• Higher attitude scores for females in management

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Development of measure of attitudes towards
professionlism

• Professionalism is difficult to define let alone
  teach or assess
• Core aspects may be generic

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Future

• Put theory into practice
• Include subjective norms and perceived
  behavioural control
• Interventions should be based on sound
  theoretical principles

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