Nurturing professional behaviours and ethical practice: From students to professionals

Medical professionalism refers to the set of values, behaviours, and ethical principles that guide the conduct of medical professionals in their interactions with patients, peers and the broader healthcare system. From a training perspective, it is easier to focus on striving to achieve excellence in medical practice and meeting “industry” accepted standards than to remediate unprofessional behaviours of practitioners.¹ Medical professionalism encompasses a commitment to providing high-quality patient care, maintaining ethical standards, and upholding the trust and respect of patients and the community. This is essential for ensuring patient safety, promoting effective healthcare delivery, and preserving the integrity of the medical profession. Systematic reviews published on unprofessional behaviours of medical students, such as failure to engage, dishonest and disrespectful behaviours, and lack of self-awareness have shown to have a negative impact on peers, teachers and patients leading to poor teamwork and provision of quality care.²

Considering the above, professional development of students and trainees is something to be crafted in the curriculum. At present, there are several curricular models to teach and provide guidance to develop appropriate professional behaviours for medical students.² The core subject content is delivered through interactive lectures, small group discussions, self-learning sessions and reflective group learning activities, which are systematically integrated into the medical curriculum longitudinally. These aim to develop the right knowledge base and subsequently, create awareness as well as appropriate behaviours using planned exposure to simulated and real clinical contexts. These intentional teaching-learning activities enhance students’ competence in the affective domain of medical professionalism. Equally significant is the role played by senior clinical practitioners as role models in this learning journey. Moreover, students are trained in the art of reflection through tools like self-assessment instruments or by engaging in systematic self-reflective processes, such as the Gibbs reflective cycle during real-life clinical encounters within a safe learning environment. This approach fosters the growth of their individual professional identities and nurtures professional behaviours. Creating a safe and conducive learning environment that would nurture the development of appropriate professional behaviours of students and trainees is thus important and necessary.

When designing such a process, the best practice is to integrate medical subject content with communication skills, empathy, and respect for patients and colleagues,³ and by providing clear outcomes and processes in the curriculum. This should start early from the very first day of medical school emphasising the importance of engaging respectfully and professionally with peers, faculty, other health professionals and patients. Providing such opportunities will lead to the development of a professional identity, first as a student in a professional programme and later as a medical professional.⁴ Teaching-learning sessions, such as discussions on professionalism through authentic case-based learning approaches must be done throughout the medical curriculum to keep students engaged and interested. Other learning activities such as role-playing and simulations will help students explore complex ethical dilemmas they might encounter in their careers.²

Faculty and experienced practitioners should serve as role models for professionalism. Students learn not only from lectures but also from observing how professionals behave in clinical and ethical situations. Establishing committees or advisory groups focused on professionalism where these groups can address concerns, provide guidance, and develop initiatives to enhance professionalism within the institution is also an important element in creating a nurturing environment for students to develop their professional behaviours. This is even more important given the existence of “negative role modelling”, which is almost inevitable, but students and trainees should be able to reflect, discuss and learn from it.⁵ Professional identity formation is shaped through individual, interactive and social processes. Therefore, it is crucial to pay adequate attention to the development of individual students and trainees, as well as foster a nurturing environment for them.

Developing one’s professionalism in medical practice and professional identity also requires systematic feedback and evaluation at specific time points to identify developmental gaps and for alignment with regulatory guidelines as the student or the trainee progresses in his or her learning journey. Contemporary medical education training institutions and health professional programmes have incorporated structured assessments to evaluate and provide feedback to students/trainees on their professional behaviours. A range of assessment tools is employed, spanning from cognitive evaluation instruments like multiple-choice questions and modified essay questions, to psychomotor and affective domain tests. This latter group of tests include Objective Structured Clinical Examinations, Workplace-Based Assessments, Mini Clinical Evaluation Exercise, Direct Observation of Procedures, Multi-Rater/Patient surveys, and Supervisor observation assessments. A comprehensive approach in the assessment of professionalism is warranted as it is even more critical to identify gaps and remediate, if necessary, in workplace-based setting.

One critical element in the overall evaluation process is to develop students’ or residents’ own self-evaluation of how well they are progressing, and identify gaps in their learning. Developing one’s ability to reflect and subsequently, apply this reflective process in day-to-day engagements is a necessary skill. Faculty members need to encourage students to reflect on their experiences and interactions with patients. Journaling, peer discussions and mentorship can help students process emotions and ethical challenges. A helpful way to develop this in the formative stages of student learning is to provide them with valid tools to engage in guided self-reflection.

In this issue of the Annals, Ho et al. discusses the development and validation of a new self-assessment tool to measure professionalism among medical students, which is a step in the right direction. Such tools will assist students to focus on specific areas of professional behaviours. Additionally, given that the tool is validated in the Singapore context, the results will be meaningful to the students reflecting on their educational and practice environments in Singapore. However, a key consideration in using such tools would be to have close guidance through mentoring and supervision. This is because unguided self-assessment of performance, especially in regulated professions has consistently been shown to be inaccurate.^7,8 Therefore, it is important to provide faculty guidance and other known student performance data obtained from standard assessment tools discussed earlier to improve the accuracy of self-assessment.⁹ Another area for consideration when employing self-evaluation tools is that they have a strong contextual and situational focus. Some items in a tool that are valid in a particular geographical or organisational context may not be relevant in another. There are several studies highlighting how medical professionalism and the individual/group identity development could vary based on context or situation.^3,4

Medical professionals are expected to adhere to a strong code of ethics, which includes principles like honesty, integrity, compassion, respect for patients, autonomy and rights. These professionals must navigate complex ethical dilemmas while putting the well-being of patients first. It is critical to provide medical students and trainees with the necessary support to develop the right professional attributes and their professional identity. Promoting and maintaining medical professionalism is a collective effort that involves medical schools, training institutions, professional associations, regulatory bodies and individual practitioners. Supporting students and trainees to develop self-reflective abilities early in their learning journey using tools discussed by Ho et al.⁶ along with proactive guidance by the faculty are important. Through these measures to nurture medical professionalism, medical professionals can ensure that patient care remains patient-centred, ethical and of the highest quality.

REFERENCES

1. Macneill PU, Samarasekera DD. Professionalism as inspiration and discernment in educating medical students and trainees. South-East Asian J Med Educ 2010;4:2-8.
2. Macneill P, Joseph R, Lysaght T, et al. A professionalism program in medical education and training–From broad values to specific applications: YLL School of Medicine, Singapore. Med Teach 2020;42:561-71.
3. Samarasekera DD, Lee SS, Yeo JH, et al. Empathy in health professions education: What works, gaps and areas for improvement. Med Educ 2023;57:86-101.
4. Findyartini A, Greviana N, Felaza E, et al. Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Med Educ 2022;22:443.
5. Armyanti I, Mustika R, Soemantri D. Dealing with negative role modelling in shaping professional physician: an exploratory study. J Pak Med Assoc 2020;70:1527-32.
6. Ho JY, Tuang V, Teo DB, et al. Development and validation of a new self-assessment tool to measure professionalism among medical students. Ann Acad Med Singap 2023;52:XXX-XX.
7. Eva KW, Regehr G. “I’ll never play professional football” and other fallacies of self‐assessment. J Contin Educ Health Prof 2008;28:14-9.
8. Karpen SC. The social psychology of biased self-assessment. Am J Pharm Educ 2018;82.
9. Lu FI, Takahashi SG, Kerr C. Myth or reality: Self-assessment is central to effective curriculum in anatomical pathology graduate medical education. Acad Pathol 2021;8:23742895211013528.