Dr Siobhan CookeClinical Teaching Fellow

Community-Based Medical Education

Can the understanding of medical students’ constructions of professionalism inform the

teaching of professionalism?

“A doctor who does the right thing, at the right time, for the right reasons—even whennobody is watching.” Ellen Cosgrove (2006:6)

Critical Incident

050% students signing in to a teaching session then failing to attend. 56 students expected 44 signed in, 22 signed in and did not attend

0Remediation task

0Revealed conflicting professional tensions and priorities that students experience

Professionalism- High Profile

Background

Medical professionalism- High profile, multi-faceted, complex and subject to change- Teaching and assessment – evolving theoryBirden, Glass, Wilson, Harrison Usherwood & Nass (2013)

Yet:– the basis of maintaining trust between society and doctors

Models of professionalism

0Traditional – individual learning, professional exam and body

0Managerial- accountability, professional managers, performance criteria – “performativity” Ball (2008)

0Democratic – demystify, alliances of teacher/students, democratisation of knowledge Whitty (2008)

Boyask, D., Boyaks, R., & Wilkinson, T. (2004). Pathways to'Involved Professionalism': Making Processes of Professional Acculturation. MedEduc Online [serial online], 19(13).

Boyask, D., Boyaks, R., & Wilkinson, T. (2004). Pathways to'Involved Professionalism': Making Processes of Professional Acculturation. MedEduc Online [serial online], 19(13).

Concepts of Professionalism Monrouxe, Rees and Hu (2011)

0 Individual –attitudes, values and behaviours Hafferty and Levinson (2008).

0 Collective – doctors’ contract with society Martimianakis, Maniate & Hodges,(2009) and Whitty (2008).

0 Interpersonal- teamwork, communities of practice Lave &Wenger (1991), Wenger (1998)

0 Complex- principles and attributes in conflict negotiated in different situational contexts Fraser & Greenhalgh, (2001), Barnett (2008)

Not mutually exclusive

Aims

0To explore students’ understanding of the constructions of medical professionalism at different years of training

0To see what influences that understanding

0To draw some tentative implications for the impact on teaching

Methods

0Qualitative research0All 1676 students on MBBS programme invited to participate0Purposive convenience sampling0Group interviews all years, intercalating and GEP programme0Narrative design, audiotaped and transcribed0Data coded -standard qualitative data analysis software

Data analysis

0Discourse analysis used by Monrouxe et al (2011), - discourse “quite simply what we do”Individual Collective InterpersonalComplexity

Results

021 students participated – 16 male and 5 female, 11 white Caucasian and 10 other ethnicities

08 interviews – 7 group (2-6 students) and one individual

0Groups – Years 1-5, a mixed year and intercalating

Themes

0Definitions (and challenging unprofessional behaviours)

0Expectations

0Development

0 Influences

Definitions

0 Interpersonal and collective discourses attributes relating to relationships with patients and team working

“if at the end of the day you’re not respecting the patient and the patient is not comfortable then you’re not being a professional.” (Year 3)

...”conducting yourself in practice but in keeping, not only within the rules and requirements of the GMC but in a manner…….. that embodies respect of patients and other colleagues and no level of, no bullying in any form whatsoever and with courtesy and always maintaining appropriate levels of behaviour.” (Year 3)

0 In contrast to previous studies which showed emphasis on the individual discourse; Hafferty (2002), Jha, Bekker, Duffy & Roberts (2006).

Definitions0 Did not cite self-care or their own health affecting their professionalism

0 Did recognise self-care - outside of the work environment in relation to social media but were also able to see its value

….” I don’t necessarily want someone 10 years down the line …well I’m not going to recommend you to go to my colleague because I remember when they were at medical school they were really inappropriate had really strange ideas, ….. the longevity of social media no one’s really tested it out, ..if in 20 years we’re going to look back on Facebook statuses or photos.”(Year 3)

“it can be a bad thing, but if you use if properly it can be ..a sort of beacon for professionalism if you show other people…..a good example of behaviour. But it’s a sort of knife-edge to balance on.” (Year 2)

Challenging unprofessional behaviours0Only act if another’s actions illegal or definite risk of harm

to patients

“ you don’t ..feel like it’s your role to do anything, unless you’re putting a patient’s life at risk” (Year 2)

0Only report to a senior if no behaviour change

0Bottom of hierarchy - major influence on reporting concerns

“you’re a med student, so seen and not heard” (Year2)

Challenging unprofessional behaviours

0 Did not know how to act and not educated“I had no idea what to do about it. I’ve had no education at all on what is the most appropriate thing to do.” (Year 4)

0 Medical school not acting on unprofessional behaviours but also not feasible“at the bottom of every page ..you will be punished for forging signatures, or it’s fraud or whatever, but no one ever investigates, no one ever, it’s not possible for them to do that” (Year 3)

0 Medical school responsibility to cultivate students’ sense of status so have the confidence to report

“we should have the confidence to feel able to do that. …I think that is partly the medical school’s responsibility, because they cultivate our sense of status within the environment that they’re bringing us into.” (Year 4)

Expectations

0In many different contexts – patients and public, clinicians on placements, medical school, GMC and themselves

“… being a doctor there comes quite a lot of loaded expectation, …people expect something, …. expect you to be caring, they’ll expect you to be intelligent and I think that changes as well ………different people have different expectations and you’ve got, it’s like being malleable within that position” (Year 3)

Developing as a medical professional

0Greater understanding of medical professionalism as students progress through their training. Hilton & Slotnick (2005), Wagner, Hendrich, Moseley & Hudson, (2007.)

Year 1

“if you come in on the first day of medical school and you are given a leaflet about what you should do and not, it seems like you have to turn off a switch and become a brand new person the next day.”

Developing as a medical professional“you might feel that you are not adapting as a person any more.” Finn, Garner and Sawdon (2010)

“I am getting the feeling I can’t make mistakes….if I can’t make mistakes now I don’t know what to do.”

Year 3“ as someone who is on the path to being a doctor”

Developing as a medical professional

Year 5“I think having that basis and understanding about what is generally expected of us,… what is professional and how to go about it, I think it’s useful for years to come.

Influences

Role models Coding frequency0 Upbringing/ family 40 GPs 60 Medical school mentors 20 Doctors as positive role models 270 Doctors as negative role models 260 Previous occupation 10 Peer mentors 90 Training video 10 Drama 10 Other health professionals 3

Influences

0 Role modelling Goldie, Dowie, Cotton & Morrison (2007)

0 Learning environment – tension between service and teaching

0 Organisational culture – wanted medical school to act as “safety net” Goldstein, Maestas, Fryer-Edwards, Wenrich, Oelschlager, Baernstein & Kimball (2006)

0 Hidden curriculum – “playing the game” log books and SJTs“in our lectures for the SJT…, it was said to us what you should do rather than what you would do.” (Year5)

Implications for teaching

0Small group – “drill” of PBLs, Medicine in Society

0Sense-making activities – narratives, reflective writing, writing newsletters, fora both on and off-line Karinieli-Miller, Vu, Holtman, Clyman & Inui (2010)

“at the end of the day, everyone has a story and it can help in some way or another.” (Year 2)

Implications for teaching

0 Student-led

0 Supported by faculty –manage and explain inconsistencies lead to deeper understanding for students and faculty

Quaintance, Arnold & Thompson (2010).

… “… if you bring in the sort of outside faculty member just to try and facilitate that, … maybe in some settings that would be useful … I think it’s best if it comes from students to students, because that ..takes it away from the whole prescriptive element and puts it in our hands.” (Year 2)

Limitations of the study

0Purposive convenience sample enhanced by snowballing0Exam term0 Insider status as a researcher0Use of professional transcription service02nd observer throughout for analysis0No claim data saturation achieved0Trustworthiness could have been enhanced

Conclusions

0Students detailed and nuanced understanding of professionalism

0Positive role modelling – central

0Role modelling and formal curriculum alone not sufficient particularly in clinical years

0Develop less “prescriptive” sense-making activities such as small group teaching and fora for discussion, student-led but supported by faculty

Conclusion

0Fear of first year medical students – a concern

0Teaching on raising concerns about how to report unprofessional behaviour needs to be developed

0Deeper understandings of professionalism by students and faculty possible in supportive, responsive organisational culture

‘‘The essential unit ofmedical practice is the occasionwhen, in the intimacy of theconsulting room, a person who isill, or believes himself to be ill,seeks the advice of a doctor whomhe trusts. This is a consultation,and all else in medicine derivesfrom it.’’Sir James Spence (1892 -1954)

References0 Ball, S. (2008) Performativity, privatisation, professionals and the state. In B. Cunningham (ed) Exploring

Professionalism. Institute of Education, University of London: Bedford Way Papers.0 Barnett, R. (2008) Critical professionalism in an age of supercomplexity. In B. Cunningham (ed) Exploring

Professionalism. Institute of Education, University of London: Bedford Way Papers.0 Birden, H., Glass, N., Wilson, I., Harrison, M., Usherwood, T., & Nass, D. (2014). Defining professionalism in

medical education: A systematic review. Medical teacher, 36(1), 47-61.0 Cosgrove, E., The Challenge of Professionalism: Environment and Assessment

http://gec.kmu.edu.tw/gec2/conf/951209/file/06-Ellen_Cosgrove.pdf (accessed 18/4/2014)0 Finn, G., Garner, J., & Sawdon, M. (2010). ‘You’re judged all the time’ Students’ views on professionalism: a

multicentre study. Medical education, 44(8), 814-825.0 Fraser, S.W., Greenhalgh, T. (2001) Complexity science: coping with complexity: educating for capability British

Medical Journal, 323 (7316), 799-803.0  General Medical Council (2013) Good Medical Practice. London: GMC.0 Goldie, J., Dowie, A.L., Cotton, P. & Morrison, J. (2007) Teaching professionalism in the early years of a medical

curriculum: a qualitative study Medical Education, 41, 610-617.

References0  Goldstein, E. A., Maestas, R. R., Fryer-Edwards, K., Wenrich, M. D., Oelschlager, A. M. A., Baernstein, A., &

Kimball, H. R. (2006). Professionalism in medical education: an institutional challenge. Academic Medicine, 81(10), 871-876.

0 Hafferty, F.W. (2002) What Medical Students Know about Professionalism Mount Sinai Journal of Medicine, 69 (6), 385 – 397.

0 Hafferty, F.W. & Levinson, D. (2008) Moving beyond nostalgia and motives: towards a complexity science view of medical professionalism Perspectives in Biology and Medicine 51(4), 599-615.

0  Hilton, S.R., Slotnick, H.B. (2005) Proto-professionalism: how professionalization occurs across the continuum of medical education Medical Education, 39 (1), 58-63.

0 Jha, V., Bekker, H.L., Duffy, S.R.G. & Roberts, T.E. (2006) Perceptions of professionalism in medicine: a qualitative study Medical Education, 40 (10), 1027 – 1036.

0 Karnieli-Miller, O., Vu, T. R., Holtman, M. C., Clyman, S. G., & Inui, T. S. (2010). Medical students' professionalism narratives: a window on the informal and hidden curriculum. Academic Medicine, 85(1), 124-133.

0 Lave, J., Wenger, E. (1991) Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.

0 Martimianakis, M.A., Maniate, J.M. & Hodges, B.D.(2009) Sociological interpretations of professionalism Medical Education, 43 (9), 829 -837.

References0 Monrouxe, L.V., Rees, C.E. & Hu, W. (2011) Differences in medical students’ explicit discourses of

professionalism: acting, representing, becoming Medical Education, 45 (6), 585-602.0 Quaintance, J. L., Arnold, L., & Thompson, G. S. (2010). What students learn about professionalism from faculty

stories: an “appreciative inquiry” approach. Academic Medicine, 85(1), 118-123.0 Wagner, P., Hendrich, J., Moseley, G. & Hudson, V. (2007) Defining medical professionalism: a qualitative study

Medical Education, 41 (3), 288-294.0 Wenger, E. (1998) Communities of Practice. Cambridge: Cambridge University Press.0 Whitty, G. (2008) Changing modes of teacher professionalism: traditional, managerial, collaborative and

democratic. In B. Cunningham (ed) Exploring Professionalism. Institute of Education, University of London: Bedford Way Papers

Acknowledgments

0Students who participated in the project0Catherine O’Keeffe and Mark Newman, IOE0Sandra Nicholson0Moira Kelly0Community-Based Medical Education Team0Stephen, Peter, Una and Michael Yates