Senior residents' views on the meaning of professionalism and how they learn about it

Empathy Among Medical Students: An Exploratory Cross-Sectional Survey

Context In the context of healthcare, effective communication and empathy are fundamental skills for physicians, as empathy correlates positively with patient satisfaction, compliance, treatment adherence, and lower rates of physician burnout, depression and anxiety. This study aimed to assess empathy levels and related factors among undergraduate medical students. Methods A cross-sectional study in a Central Indian medical institute examined empathy levels and factors associated with it among medical students, utilizing various scales and statistical analyses. Results This study found that while empathy levels were relatively high among undergraduate students, there was a decline as they progressed through medical education, particularly after the first year of clinical exposure. The study identified several factors associated with empathy levels, including perceived stress, emotional separation, and social support. Notably, individuals experiencing higher levels of stress and emotional separation tended to have higher empathy levels. Conclusions The study's findings suggest that medical education should incorporate interventions to enhance empathy, including addressing stress, providing social support, and exposing students to the emotional aspects of patient care.

Does professionalism change with different sociodemographic variables? A survey of Arab medical residents

BACKGROUND

Medical professionalism reflects the commitment of physicians to their patients, society, themselves, and the profession. The study examined residents' attitudes towards professionalism and how these attitudes vary among the different demographic groups, namely gender, specialty, and year of residency.

METHODS

A proportionate random sampling strategy was used to select the study sample. Medical residents from six specialties at a large tertiary care teaching facility were invited to participate in an online survey. The survey used the modified Learners Attitude of Medical Professionalism Scale (LAMPS), which consists of five domains: respect, excellence, altruism, duty/accountability, and integrity. Chi-square, Student t-test, one-way ANOVA, factorial ANOVA, and post hoc analysis were used to examine the attitudinal differences towards professionalism among the different demographic factors.

RESULTS

The overall response rate was 82.7%. Overall, the residents' self-reported attitudes towards professionalism was positive. The highest score was for the "respect" domain (4.61), and the lowest was for "altruism" (3.67). No significant association was found between the mean scores and the three studied variables, namely, gender, specialty (surgical/nonsurgical), and level (senior/junior).

CONCLUSIONS

No significant differences were observed in the overall attitude towards professionalism among the residents regarding their year of residency, gender, and specialty. The low altruism score and absence of improvement of the total score regarding the residents' increasing experience in the profession are concerns that need remedial action. Therefore, we suggest that future research look for possible explanations by using multi-institutional surveys that explore not only the residents' attitudes, but also the trainers' attitudes and practice, work situations, the hidden curriculum, and culture. Key messagesAttitudes towards professionalism among different demographic groups of residents do not show similar variations as has been reported in the literature, albeit in different sociocultural contexts.The low altruism score and absence of improvement of the total score as the residents gained more experience in the profession are concerns that need remedial action.A longitudinal study involving more than one institution for both residents and their faculty members to compare faculty scores with those of residents, while controlling for specialty and gender, may help elucidate the factors affecting attitudes towards professionalism and suggest possible means of addressing unfavourable attitudes.

Medical students' perception of professionalism climate in clinical settings

Medical professionalism has a crucial role in educating medical students. The role of professionalism in the clinical environment is therefore an important factor in medical education. This study attempts to evaluate the opinions of medical students in the teaching hospitals of Tehran University of Medical Sciences (TUMS) about the professionalism environment in this university.

A sample of 165 students filled out the Persian translation of UMKC-SOM (Climate of Professionalism Survey) questionnaire. This instrument evaluates students’ perspectives on the degree of adherence to professionalism by faculty, residents and other students.

The results of the study revealed that the total score of professionalism climate was 53.9 for faculty, 42.09 for residents, and 50.76 for students and the difference between these three groups was statistically significant (p-value < 0.01). Results of further analysis through post-hoc tests for multiple comparisons among the groups revealed that the students found their fellow students and faculty more professional than residents. The study also showed that the medical ethics course had no impact on perceptions observations (p-values > 0.05).

The study results also revealed that the students found their fellow students and faculty more professional than residents. This finding demonstrates the importance of teaching professionalism to residents since they serve as role models for students.

Further multicenter studies are needed to improve the professionalism climate in the medical teaching environment.

Gender differences in the effect of medical humanities program on medical students' empathy: a prospective longitudinal study

BACKGROUND

Previous studies have suggested that Medical students' empathy declines during medical school, especially during the clinical studies. The aim of this study was to examine. Changes in medical students' empathy during their first clinical experience, and to determine the impact of gender and humanities curriculum on empathy changes.

METHODS

In this prospective longitudinal study, 262 4th year students from three consecutive classes were assessed. Empathy was assessed before and at 4th-year-end, using the Jefferson Scale of Physician Empathy-Student Version (JSPE-S). The three classes differed in humanities curriculum [limited Medical Humanities (MH_(lim)) vs. extended Medical Humanities (MH_(ext))], and in admission system [Personal Interview (PI) vs. multiple mini interviews (MMI)].

RESULTS

Overall, there was a small but significant decrease in JSPE-S during the fourth year (114.40 ± 11.32 vs. 112.75 ± 14.19, p = 0.034). Among men there was a statistically significant decline in JSPE-S during the fourth year, and the MH_(ext) (but not the MH_(lim)) was associated with the decline (t₍₃₅₎ = 2.38, p = 0.023). Women students showed no decline in empathy during the fourth-year of studies, regardless of type of humanities program. In addition, women who participated in MH_(ext) had a higher JSPE-S scores during the 4th -year as compared to women who participated in MH_(lim).

CONCLUSION

Pre-clinical humanities program was associated with a decline in empathy among men medical students during the fourth-year of medical studies. Gender differences in response to medical humanities programs require further study.

Osler Centenary Papers: Would Sir William Osler be a role model for medical trainees and physicians today?

If Sir William Osler were alive and practising as one of our contemporary colleagues, would he be viewed as a role model by medical trainees and other physicians? Recently published literature has sought to define clinical excellence; this characterisation of physician performance establishes a context in which role models in medicine can be appraised. Building on this framework, we present rich anecdotes and quotes from Sir William Osler himself, his colleagues, and his students to consider whether Osler would have been regarded as a role model for clinical excellence today. This paper illustrates convincingly that William Osler indeed personified clinical excellence and would have been appreciated as a consummate role model if he were alive and on a medical school’s faculty today. However, a century has passed since his death, and he is not sufficiently visible today to serve as a role model to modern medical trainees and physicians. Moreover, we speculate that Osler himself would not have wanted to be a role model for today’s trainees, as he emphasised that medicine is best learned from teachers at the bedside—a place where he cannot be. Reanimating Osler through rich stories and inspiring quotes, and translating his example of clinical excellence into modern clinical practice, can remind us all to carry Oslerian virtues with us in our professional work.

Clinical teachers as positive and negative role models: an explanatory sequential mixed method design

Today, role modeling is an essential component of medical education that facilitates the students' learning and affects their attitudes and behaviors. Hence, this study aimed to examine the characteristics of positive and negative role models using a mixed method approach. In the quantitative part, data were collected using a questionnaire with 24 items. The research population included medical students who were in their clinical period between May 2017 and December 2018 at Shiraz University of Medical Sciences (n = 750). A total of 282 questionnaires were completed by these students, and in the qualitative part, 26 semi-structured interviews were conducted with them.

The most important components of role modeling for students included: individual characteristics, clinical skills and competence, teaching skills and professionalism, in that order. The qualitative analysis confirmed the results of the quantitative analysis. The findings showed that the characteristics of a negative role model can also be classified in four main components. The results demonstrated that 46.8% of the students identified one or more medical teachers as negative models.

Students paid attention to not only the positive characteristics of their teachers, but also their negative features, stating that they had been influenced by both. Therefore, it can be concluded that clinical teachers should improve their performance as positive role models through reducing these negative effects and reinforcing positive characteristics.

Empathy in dental care - the role of vicarious trauma

OBJECTIVES

In health care, empathy is associated with compassion, thoughtfulness, attentiveness and caring. While empathy is perceived as desirable and positive, it can potentially be associated with negative aspects, such as secondary traumatic stress or vicarious trauma (VT). VT addresses the secondary vicarious influences of patients' pain and discomfort on clinicians. Dentists are routinely exposed to patients' anxiety, pain and discomfort. These may lead to VT, which in turn can affect empathy. The objectives of the present study were to examine the existence of VT among dentists and its association with their empathic approach.

MATERIALS AND METHODS

Two-hundred and fifty dentists were approached personally and by mail, and asked to complete: (i) the Jefferson Scale of Physician Empathy - Health Professionals; (ii) the Vicarious Trauma Scale; and (iii) demographic, personal and professional data, including age, definition of professional speciality, number of working hours per week and number of sleeping hours per night.

RESULTS

A total of 200 dentists responded (80% response rate). No differences were found between genders regarding empathy or VT. Dentists who have been accredited as a specialist in one of the dental fields (dental specialists) presented higher empathy scores than general practitioners. VT correlated positively with number of working hours per week and negatively with empathy. The best predictor of empathy was number of sleeping hours per night, followed by VT and age.

CONCLUSIONS

Empathy in the clinical setting is closely associated with secondary VT among dentists. Decreasing dentists' VT may benefit dentists' empathy and through this lead to better clinical outcomes.

Residents' perspective on professionalism in the learning environment

All accrediting organizations for medical education in the US require teaching hospitals to ensure the learning environment fosters professionalism behaviors of trainees and faculty. This study analyzes the learning environment of professionalism from the perspective of residents. An on-line anonymous survey that explored the learning climate of professionalism was sent to all residents at the University of Virginia in 2013-14. Residents rated their personal commitment, their residency program's, and the institution's commitment to demonstrating professionalism behaviors, described professionalism education, reasons for not participating in curricular offerings, the quality of role modeling, and barriers to professionalism. Nearly half the residents completed the survey (47%, N = 365/771). Residents rated their personal commitment and commitment of their residency program significantly greater than the institution's commitment to demonstrating professionalism.(p < 0.001) They noted only 25% of faculty modeled these behaviors all the time; and more than half stated poor role modeling impacted their attitudes about the importance of professionalism. Other areas in need of improvement include communicating with patients with cultural differences, and inter-professional teamwork. Despite accreditation requirements for learning environments, residency curricula, and faculty development programs to promote professionalism, residents perceive their commitment to professionalism greater than the institution where they work.

Perceptions of Unprofessional Attitudes and Behaviors: Implications for Faculty Role Modeling and Teaching Professionalism During Pathology Residency

CONTEXT

- Changes occurring in medicine have raised issues about medical professionalism. Professionalism is included in the Core Competencies and Milestones for all pathology residents. Previous studies have looked at resident professionalism attitudes and behaviors in primary care but none have looked specifically at pathology.

OBJECTIVE

- To examine behavior and attitudes toward professionalism within pathology and to determine how professionalism is taught in residency programs.

DESIGN

- Surveys were sent to all College of American Pathologists junior members and all pathology residency program directors, and responses were compared.

RESULTS

- Although no single behavior received the same professionalism rating among residents and program directors, both groups identified the same behaviors as being the most unprofessional: posting identifiable patient information or case images to social media, making a disparaging comment about a physician colleague or member of the support staff on social media or in a public hospital space, and missing work without reporting the time off. Faculty were observed displaying most of these behaviors as often or more often than residents by both groups. The most common means to teach professionalism in pathology residencies is providing feedback as situations arise and teaching by example. Age differences were found within each group and between groups for observed behaviors and attitudes.

CONCLUSIONS

- As teaching by example was identified as a common educational method, faculty must be aware of the role their behavior and attitudes have in shaping resident behavior and attitudes. These results suggest a need for additional resources to teach professionalism during pathology residency.

Exclusion of Residents From Surgery-Intensive Care Team Communication: A Qualitative Study

OBJECTIVE

Communication competency is an important aspect of postgraduate training and patient care delivery in all specialties and clinical domains. This study explored staff surgeon and intensivist perceptions of and experiences with residents' communication with a view toward fostering high quality interspecialty team communication in the surgical intensive care unit.

DESIGN

A qualitative study using semistructured interviews. Data were analyzed iteratively and inductively as per standard qualitative thematic approach.

SETTING

University of Toronto, Toronto, Canada.

PARTICIPANTS

A total of 15 staff surgeons and intensivists who collaborate in patient care in the surgical intensive care unit.

RESULTS

The phenomenon of "resident bypass" emerged, resulting from staff surgeon and intensivist perceptions that residents threaten the quality of interspecialty team communication. Clear patterns and preferences for resident exclusion from this communication were present. A total of 5 interrelated drivers of resident bypass were discovered: lack of trust, lack of specialized knowledge, poor system design, need for timely communication, and residents' inadequate contribution to decision-making. Surgical and intensive care staff were dissatisfied with the structure of residents' roles in interspecialty team communication. Concerns about communication gaps, patient care continuity, and patient safety were expressed.

CONCLUSIONS

Surgical and intensive care staff exclude residents from interspecialty team communication for the benefit of patient safety and care continuity, but this limits opportunities for residents to develop communication skill and competence. Efforts are needed to effectively integrate surgery and intensive care residents in interspecialty attending-resident communication in ways that are meaningful for both patient care and postgraduate training. The implications for medical education are discussed.

Trends in nursing ethics research: Mapping the literature production

BACKGROUND

There have been a number of debates in the field of nursing ethics. Researchers have focused on various aspects of nursing ethics, such as professional ethics, professional, nursing and ethical values. Within this research, a variety of literature reviews have been conducted, but to the best of our knowledge, bibliometric mapping has not yet been used.

OBJECTIVE

This article aims to analyse the production of literature within nursing ethics research.

RESEARCH DESIGN

In order to examine publishing patterns, we focused on publishing dynamics, prolific research entities and the most-cited articles. We additionally visualised the content of the literature using a novel mixed-method approach, combining bibliometric analysis and mapping with thematic analysis. Ethical considerations: In our study, ethical review was not required.

FINDINGS

A total of 1416 information sources were found in the Scopus database. Overall, literature production has increased; however, in recent years, the quantity of published material has begun to decrease. The most prolific countries are the United States, the United Kingdom and Canada, and the most prolific source titles are Nursing Ethics, Journal of Advanced Nursing and Nursing Times. Lately, research in the field of nursing ethics has been focused more on life care (providing for the basic needs of older residents), moral distress and community nursing.

DISCUSSION

The dynamics of research literature production showed an exponential rise in the number of published information sources - a rise which started in the period between 1974 and 1998. Since that period, the trend has stabilised, which might indicate that nursing ethics research is starting a transition to a mature phase.

CONCLUSION

The innovative use of bibliometric analysis and mapping, together with thematic analysis, is a useful tool for analysis of research production in the field of nursing ethics. The results presented can be an excellent starting point for literature reviews and more exhaustive data, information and knowledge seeking.

Medical Students' Perceptions of Clinical Teachers as Role Model

Introduction

Role models facilitate student learning and assists in the development of professional identity. However, social organization and cultural values influence the choice of role models. Considering that the social organization and cultural values in South East Asia are different from other countries, it is important to know whether this affects the characteristics medical students look for in their role models in these societies.

Methods

A 32 item questionnaire was developed and self-administered to undergraduate medical students. Participants rated the characteristics on a three point scale (0 = not important, 1 = mildly important, 2 = very important). One way ANOVA and student's t-test were used to compare the groups.

Results

A total of 349 (65.23%) distributed questionnaires were returned. The highest ranked themes were teaching and facilitating learning, patient care and continuing professional development followed by communication and professionalism. Safe environment and guiding personal and professional development was indicated least important. Differences were also observed between scores obtained by males and females.

Conclusion

Globally there are attributes which are perceived as essential for role models, while others are considered desirable. An understanding of the attributes which are essential and desirable for role models can help medical educators devise strategies which can reinforce those attributes within their institutions.

Facilitating the initiation of the physician's professional identity: Cornell's urban semester program

Calling for major reform in medical education, the Carnegie Institute report 'Educating Physicians' espoused the importance of assisting student trainees in forming their professional identities. Here, we consider the question: At what educational stage should future physicians begin this process? The literature suggests that the process begins when students matriculate in medical school; we posit, however, that premedical students can begin their proto-professional development as college undergraduates. We describe here the pedagogy of Cornell University's urban semester program (USP), which enables college students to participate in shadowing experiences as part of an integrated structured study programme. USP students report improved communicative competency, changes in their perceptions and attitudes toward medical practice, and powerful influences on their personal and professional development upon completion of the programme. We suggest the solution to the question of 'When and under what conditions should shadowing take place?' is to utilize a structure that combines the exposure of college students to the professional environment with a didactic and self-reflective curriculum, thereby supporting students in their early professional development. We conclude that educational efforts aimed at developing professional identity and behaviour can begin before students enter medical school.

The effect of patient-centeredness and gender of professional role models on trainees' mentalization responses. Implications for film-aided education

OBJECTIVE

To examine how certain characteristics of film-presented practitioner role-models influence trainees' mentalization.

METHODS

In an experimental setting, psychology students watched four film clips presenting a patient-practitioner session; the clips varied in the practitioner's patient-centeredness (positive vs. negative) and gender. Participants commented on the practitioner's thoughts, emotions and intentions through the session. Analysis of 116 comments focused on the effect of patient-centeredness and gender variables on mentalization and judgment utterances.

RESULTS

Negative role-models and female role-models induced higher levels of mentalization compared to positive and male role-models. There was no gender difference in the level of mentalization; however male participants gave more judgmental responses than female participants. The patient-centeredness had a larger effect on mentalization when trainees described the opposite gender role-model.

CONCLUSION

In a systematic comparison, students' capacity for mentalization differed according to role-models' patient-centeredness and gender, as well as the gender-match of students with role-models.

PRACTICE IMPLICATIONS

When working with film-presented role-models, educators should be aware of the differences in the level of mentalization elicited by positive and male role-models, as opposed to negative and female role-models. Educators should also consider the gender-match between trainees and role-models, therefore students should be exposed to both cross- and same-gender role-models.

Clinical examiners, simulated patients, and student self-assessed empathy in medical students during a psychiatry objective structured clinical examination

OBJECTIVES

This study aims to assess and compare objective and subjective scores of empathy in final-year medical students by using firstly a validated student self-assessment just prior to the psychiatry objective structured clinical examination (OSCE), and then comparing this to clinical examiner's and simulated patient's (SP's) assessments of empathy of students using a Global Rating of Empathy scale (GRE) during a psychiatry OSCE.

METHODS

In 2011, all final-year medical students in the University College Dublin were invited to complete a subjective, self-assessed empathy questionnaire (The Jefferson scale of physician empathy-student version (JSPE-S)). They were also assessed for empathy in four OSCEs by the clinical examiner and the SP acting in that OSCE scenario.

RESULTS

Included in the analysis were 163 of 184 final-year students JSPE-S (88.6%) questionnaires. The female students scores on the JSPE-S were significantly higher than those of their male peers (t=3.34, p=0.001). Concurrent validity was greater between the SPs' assessments of empathy in the OSCE and the JSPE-S score than between the clinical examiners assessments of empathy and the JSPE-S score (r=0.23, p<0.005; r=0.14, p<0.08). Inter-rater reliability of SP's and clinical examiner's using the GRE was found to be high (F=0.868 (df=171, 171), p value<0.001).

CONCLUSIONS

SPs may be valid assessors of empathy in medical students during an OSCE.

Advanced medical students' experiences and views on professionalism at Kuwait University

BACKGROUND

Professionalism is a core competency in the medical profession worldwide. Numerous studies investigate how this competency is taught and learned. However, there are few reports on the students' views and experiences with professionalism especially in the Arab world. Our aim was to explore the experiences and views of Kuwait final-year medical students on professionalism.

METHODS

This was a questionnaire study of final-year medical students at Kuwait University (n = 95). Open- and close-ended questions were used to determine the students' experiences and views on: definition, teaching, learning, and assessment of professionalism.

RESULTS

Eighty-five of the students completed the questionnaire (89.5%). A total of 252 attributes defining professionalism were listed by our respondents. The majority (98.0%) of these attributes were categorized under the CanMEDS theme describing professionalism as commitment to patients, profession, and society through ethical practice. The most helpful methods in learning about professionalism for the students were contact with positive role models, patients and families, and with their own families, relatives and peers. The students' rating of the quality and quantity of teaching professionalism in the institution was quite variable. Despite this, 68.2% of the students felt very or somewhat comfortable explaining the meaning of medical professionalism to junior medical students. Almost half of the students felt that their education had always or sometimes helped them deal with professionally-challenging situations. Majority (77.6%) of the students thought that their academic assessments should include assessment of professionalism and should be used as a selection criterion in their future academic careers (62.3%). Most of the students discussed and sought advice regarding professionally-challenging situations from their fellow medical students and colleagues. Seventy-five (88.2%) students did not know which organizational body in the institution deals with matters pertaining to medical professionalism.

CONCLUSION

This study highlights the influence of the curriculum, the hidden curriculum, and culture on medical students' perception of professionalism. Medical educators should take in account such influences when teaching and assessing professionalism. Future research should aim at creating a framework of competencies that addresses professionalism in a context suitable for the Arabian culture.

Frequency and negative impact of medical student mistreatment based on specialty choice: a longitudinal study

PURPOSE

According to responses to the Association of American Medical Colleges' Medical School Graduation Questionnaire, 17% to 20% of medical students report mistreatment. This study examined the longitudinal nature of medical student mistreatment based on specialty choice.

METHOD

From 2003 to 2010, the authors surveyed all medical students at one institution at the end of their third year, assessing the frequency and impact of any mistreatment based on specialty choice. They analyzed quantitative data on the frequency, impact, sources, and trends over time and qualitative data from students' open-ended responses and compared data by specialty interest (primary care versus subspecialty).

RESULTS

Of the 1,059 students sent the survey, 801 (76%) responded. Mistreatment based on specialty choice was common. The frequency and impact of such mistreatment were tightly correlated (Pearson r = 0.8, P < .001). The nature of mistreatment differed between students interested in primary care and those interested in a subspecialty, occurred more commonly on specific clerkships, and originated most often from resident physicians. Students perceived that teaching opportunities and evaluations were negatively affected by their specialty choice. An association was found between the theme of respect and students reconsidering their specialty choice. These patterns of mistreatment were stable over the study period, despite several professionalism initiatives.

CONCLUSIONS

Mistreatment based on specialty choice is a distinct and common phenomenon perpetuated by faculty, residents, and peers. More research is needed to explore the potential hidden curriculum drivers of these findings and to develop interventions specifically targeting this type of mistreatment.

A Delphi study of medical professionalism in Arabian countries: the Four-Gates model

BACKGROUND

Medical professionalism has been described as a set of attributes and behaviors, yet the Western frameworks of medical professionalism may not resonate with the cultural values of non-Western countries.

AIM

This study aims to formulate a professionalism framework for healthcare providers as interpreted by local medical professionals in Arabian countries.

METHODS

A purposive sample of 17 experts from diverse disciplines participated in a Delphi study in three rounds. Consensus was identified by content analysis and by numerical analysis of responses on the basic attributes of medical professionalism in Arabian context.

RESULTS

Eight professional traits were shortlisted and coupled in four themes (Gates): dealing with self, dealing with tasks, dealing with others and dealing with God. Self-accountability and self-motivation were interpreted from a faithful viewpoint as "taqwa" and "ehtesab", respectively, in Arabic.

DISCUSSION

The Four-Gates Model helps in better understanding of medical professionalism as grounded in the minds and culture of Arabs. The model may act as a genuine framework for teaching and learning of medical professionalism in Arab medical schools.

CONCLUSION

The study highlights the divergent interpretation of medical professionalism between Western and Arabian contexts. The Four-Gates Model may work for faith-driven societies, but not for non-Muslims Arabs students or teachers or in institutions with humanistic values.

Professionalism education should reflect reality: findings from three health professions

CONTEXT

Despite a growing and influential literature, 'professionalism' remains conceptually unclear. A recent review identified three discourses of professionalism in the literature: the individual; the interpersonal, and the societal-institutional. Although all have credibility and empirical support, there are tensions among them.

OBJECTIVES

This paper considers how these discourses reflect the views of professionalism as they are expressed by students and educator-practitioners in three health care professions, and their implications for education.

METHODS

Twenty focus groups were carried out with 112 participants, comprising trainee and educator paramedics, occupational therapists and podiatrists. The focus group discussions addressed participants' definitions of professionalism, the sources of their perceptions, examples of professional and unprofessional behaviour, and the point at which participants felt one became 'a professional'.

RESULTS

Analysis found views of professionalism were complex, and varied within and between the professional groups. Participants' descriptions of professionalism related to the three discourses. Individual references were to beliefs or fundamental values formed early in life, and to professional identity, with professionalism as an aspect of the self. Interpersonal references indicated the definition of 'professional' behaviour is dependent on contextual factors, with the meta-skill of selecting an appropriate approach being fundamental. Societal-institutional references related to societal expectations, to organisational cultures (including management support), and to local work-group norms. These different views overlapped and combined in different ways, creating a complex picture of professionalism as something highly individual, but constrained or enabled by context. Professionalism is grown, not made.

CONCLUSIONS

The conceptual complexity identified in the findings suggests that the use of 'professionalism' as a descriptor, despite its vernacular accessibility, may be problematic in educational applications in which greater precision is necessary. It may be better to assume that 'professionalism' as a discrete construct does not exist per se, and to focus instead on specific skills, including the ability to identify appropriate behaviour, and the organisational requirements necessary to support those skills.

Postgraduate training in medical professionalism

Medical professionalism receives little attention in postgraduate medical education, despite its importance in producing clinically and professionally competent specialists. Guidance for translating professionalism from postgraduate curricula into practice is lacking. This is the challenge for every postgraduate training programme.

Defining professionalism in medical education: a systematic review

INTRODUCTION

We undertook a systematic review and narrative synthesis of the literature to identify how professionalism is defined in the medical education literature.

METHODS

Eligible studies included any articles published between 1999 and 2009 inclusive presenting viewpoints, opinions, or empirical research on defining medical professionalism.

RESULTS

We identified 195 papers on the topic of definition of professionalism in medicine. Of these, we rated 26 as high quality and included these in the narrative synthesis.

CONCLUSION

As yet there is no overarching conceptual context of medical professionalism that is universally agreed upon. The continually shifting nature of the organizational and social milieu in which medicine operates creates a dynamic situation where no definition has yet taken hold as definitive.

Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25

INTRODUCTION

We undertook a systematic review to identify the best evidence for how professionalism in medicine should be taught.

METHODS

Eligible studies included any articles published between 1999 and 2009 inclusive. We reviewed papers presenting viewpoints and opinions as well as empirical research. We performed a comparative and thematic synthesis on all papers meeting inclusion criteria in order to capture the best available evidence on how to teach professionalism.

RESULTS

We identified 217 papers on how to teach professionalism. Of these, we determined 43 to be best evidence. Few studies provided comprehensive evaluation or assessment data demonstrating success. As yet, there has not emerged a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum.

DISCUSSION

Evident themes in the literature are that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programmes, and are widely held to be the most effective techniques for developing professionalism. While it is generally held that professionalism should be part of the whole of a medical curriculum, the specifics of sequence, depth, detail, and the nature of how to integrate professionalism with other curriculum elements remain matters of evolving theory.

Walking a fine line: is it possible to remain an empathic physician and have a hardened heart?

Establishing an empathic physician-patient relationship is an essential physician skill. This chapter discusses the sexually dimorphic aspects of the neural components involved in affective and cognitive empathy, and examines why men and women medical students or physicians express different levels of empathy. Studies reveal levels of medical student affective or cognitive empathy can help reveal which medical specialty a student will enter. The data show students or physicians with higher empathy enter into specialties characterized by large amounts of patient contact and continuity of care; and individuals with lower levels of empathy desire specialties having little or no patient contact and little to no continuity of care. Burnout and stress can decrease the empathy physicians had when they first entered medical school to unacceptable levels. Conversely, having a too empathetic physician can let patient conditions and reactions interfere with the ability to provide effective care. By learning to blunt affective empathic responses, physicians establish a certain degree of empathic detachment with the patient in order to provide objective care. However, a physician must not become so detached and hardened that their conduct appears callous, because it is still important for physicians, especially those in specialties with a large amount of patient contact, to use empathic communication skills.

Medical professional values and education: a survey on italian students of the medical doctor school in medicine and surgery

Background:

The values such as participation/empathy, communication/sharing, self-awareness, moral integrity, sensitivity/trustfulness, commitment to ongoing professional development, and sense of duty linked to the practice of the medical professionalism were defined by various professional oaths.

Aims:

The aim of this study was to evaluate how these values are considered by the students of the degree course of medicine.

Materials and Methods:

Four hundred twenty three students (254 females, 169 males) taking part of the first, fourth, and fifth years of the degree course in medicine were asked to answer seven questions. Pearson's Chi-square, Wilcoxon rank sum test, and Kruskal–Wallis test were used for the statistical analysis.

Results:

The survey showed a high level of knowledge and self-awareness about the values and skills of medical profession. In particular, the respect, accountability, and the professional skills of competence were considered fundamental in clinical practice. However, the students considered that these values not sufficiently present in their educational experience.

Conclusions:

Teaching methods should be harmonized with the contents and with the educational needs to ensure a more complex patient-based approach and the classical lectures of teachers should be more integrated with learning through experience methods.

Proficiency of surgical faculty and residents with ethical dilemmas: is modeling enough?

OBJECTIVE

Professionalism, an Accreditation Commission for Graduate Medical Education (ACGME) competency, embraces the concept of adherence to ethical principles. Despite this, most surgical residencies do not currently include ethics as part of their core curriculum. Further, expertise in effectively managing ethical dilemmas is frequently obtained via modeling after the attending physician. This study evaluated surgical faculty (SF) and residents (SR) on their understanding of basic ethical principles and their overall confidence in translation of these principles into clinical practice. The objective was to determine if there are any differences in the overall levels of knowledge and confidence in ethics between SR and SF.

DESIGN AND SETTING

Immediately before the first session of a Kamangar Grant supported monthly Ethics Forum, all SF and SR completed a Pre-Curriculum Questionnaire (PCQ) on their knowledge about ethical principles and their confidence in dealing with ethical issues. PQC contained 13 multiple-choice and true/false knowledge questions and 8 questions evaluating confidence rated on a 5-point Likert scale.

PARTICIPANTS

Surgical faculty (SF) (n = 16) and SR (n = 36). Knowledge and confidence scores were compared between SR and SF, using Student t-test analysis to evaluate differences between groups.

RESULTS

No significant differences were found in ethical knowledge scores between faculty and residents. Faculty confidence is higher than resident (p < 0.05). Further, female faculty confidence is higher than that of their male counterparts (p < 0.05).

CONCLUSIONS

While SF are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different from that of SR. Female SF report greater self-confidence over their male counterparts. In total, SF may not possess the foundation to effectively mentor residents in appropriate ethical principles and their translation to clinical practice. This study supports the need for both SR and SF to engage in an integrated education program in ethics to promote on-going dialogue in this complex topic.

Does empathy change in first-year dental students?

INTRODUCTION

Professionalism is a central tenet of the dental undergraduate curriculum. Dental undergraduate curricula and standards expect the dentist to put the patient's interests first, and in this respect, an important attitude is empathy.

OBJECTIVE

This study examined the self-reported empathy levels of first-year dental students before and after an early analytical exposure to behavioural sciences and the clinical encounter.

METHOD

First-year dental undergraduates were given an attitudinal questionnaire to complete before and after the behavioural science course. The questionnaire consisted of the HP version of the Jefferson Scale of Physician Empathy and the Patient-Practitioner Orientation Scale. Paired non-parametric tests and Spearman's Rho correlations, along with simple descriptive statistics, were used to test the statistical significance of observations.

RESULTS

A total of 66 paired questionnaires were returned, giving a response rate of 75%. There were no correlations between age and total mean score of JSPE or PPOS, and no gender differences. There was a significant increase (P<0.01) in empathy as measured by the JSPE between pre- and post-course scores. The PPOS did not record any significant change in the sharing, caring or total scale scores pre- to post-course.

CONCLUSION

The modified JSPE has potential utility in assessing the cognitive-affective aspect of dental students' empathy. Using the JSPE, short-term measurable empathy changes can be detected in first-year dental undergraduates after the structured and assessed analytical introduction to the clinical encounter and environment.

Integrating professionalism into the curriculum: AMEE Guide No. 61

Professional values and behaviours are intrinsic to all medical practice, yet remain one of the most difficult subjects to integrate explicitly into a curriculum. Professionalism for the twenty-first century raises challenges not only to adapting the course to changing societal values but also for instilling skills of ongoing self-directed continuous development in trainees for future revalidation. This Guide is based on the contemporary available literature and focuses on instilling Professionalism positively into both undergraduate and postgraduate training deliberately avoiding the more negative aspects of Fitness to Practise. The literature on Professionalism is extensive. An evidence-based approach has been taken throughout. We have selected only some of the available publications to offer practical advice. Comprehensive reviews are available elsewhere (van Mook et al. 2009a-g). This Guide takes a structured stepwise approach and sequentially addresses: (i) agreeing an institutional definition, (ii) structuring the curriculum to integrate learning across all years, (iii) suggesting learning models, (iv) harnessing the impact of the formal, informal and hidden curricula and (v) assessing the learning. Finally, a few well-evaluated case studies for both teaching and assessment have been selected to illustrate our recommendations.

Stability of empathy among undergraduate medical students: a longitudinal study at one UK medical school

BACKGROUND

Empathy is important to patient care. The prevailing view is that empathy declines during university medical education. The significance of that decline has been debated.This paper reports the findings in respect of two questions relating to university medical education: 1. Do men and women medical students differ in empathy? 2. Does empathy change amongst men and women over time?

METHODS

The medical course at the University of Cambridge comprises two components: Core Science (Years 1-3) and Clinical (Years 4-6). Data were obtained from repeated questionnaire surveys of medical students from each component over a period of four years: 2007-2010. Participation in the study was voluntary.Empathy was measured using two subscales of the Interpersonal Reactivity Index: IRI-EC (affective empathy) and IRI-PT (cognitive empathy). We analysed data separately for men and women from the Core Science and Clinical components. We undertook missing value analyses using logistic regression separately, for each measure of empathy, to examine non-response bias. We used Student's t-tests to examine gender differences and linear mixed effects regression analyses to examine changes over time. To assess the influence of outliers, we repeated the linear mixed effects regression analyses having excluded them.

RESULTS

Women displayed statistically significant higher mean scores than men for affective empathy in all 6 years of medical training and for cognitive empathy in 4 out of 6 years - Years 1 and 2 (Core Science component) and Years 4 and 5 (Clinical component).Amongst men, affective empathy declined slightly during both Core Science and Clinical components. Although statistically significant, both of these changes were extremely small. Cognitive empathy was unchanged during either component. Amongst women, neither affective empathy nor cognitive empathy changed during either component of the course.Analysis following removal of outliers showed a statistically significant slight increase in men's cognitive empathy during the Core Science component and slight decline in women's affective empathy during the Clinical component. Again, although statistically significant, these changes were extremely small and do not influence the study's overall conclusions.

CONCLUSIONS

Amongst medical students at the University of Cambridge, women are more empathetic than men (a generally observed phenomenon). Men's affective empathy declined slightly across the course overall, whilst women's affective empathy showed no change. Neither men nor women showed any change in cognitive empathy during the course. Although statistically significant, the size of such changes as occurred makes their practical significance questionable. Neither men nor women appear to become meaningfully less empathetic during their medical education at the University of Cambridge.

Intensive care medicine trainees' perception of professionalism: a qualitative study

The Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was performed. The moderator asked participants to clarify the terms professionalism and professional behaviour, and to explore the questions "How do you learn the mentioned aspects?" and "What ways of learning do you find useful or superfluous?". Qualitative data analysis software (MAXQDA2007) facilitated analysis using an inductive coding approach. Thirty-five fellows across eight groups participated. The themes most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organisation and management. Medical knowledge, expertise and technical skills seem to become more tacit when training progresses. Topics can be categorised into themes of workplace-based learning, by gathering practical experience, by following examples and receiving feedback on action, including learning from own and others' mistakes. Formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. The emerging themes considered most relevant for intensivists were adequate communication skills and keeping boundaries with patients and relatives. Professionalism is mainly learned 'on the job' from role models in the intensive care unit. Formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. Self-reflection as a starting point for learning professionalism was stressed.

Observation, reflection, and reinforcement: surgery faculty members' and residents' perceptions of how they learned professionalism

PURPOSE

To explore perceptions of how professionalism is learned in the current academic environment. Professionalism is a core competency in surgery (as in all of medical practice), and its presence or absence affects all aspects of clinical education and practice, but the ways in which professional values and attitudes are best transmitted to developing generations of surgeons have not been well defined.

METHOD

The authors conducted 34 semistructured interviews of individual surgery residents and faculty members at two academic institutions from 2004 to 2006. Interviews consisted of open-ended questions on how the participants learned professionalism and what they perceived as challenges to learning professionalism. Two researchers analyzed the interview transcripts for emergent themes by using a grounded-theory approach.

RESULTS

Faculty members' and residents' perceptions of how they learned professionalism reflected four major themes: (1) personal values and upbringing, including premedical education experiences, (2) learning by example from professional role models, (3) the structure of the surgery residency, and (4) formal instruction on professionalism. Of these, role modeling was the dominant theme: Participants identified observation, reflection, and reinforcement as playing key roles in their learning from role models and in distinguishing the sometimes blurred boundary between positive and negative role models.

CONCLUSIONS

The theoretical framework generated out of this study proposes a focus on specific activities to improve professional education, including an active approach to role modeling through the intentional and explicit demonstration of professional behavior during the course of everyday work; structured, reflective self-examination; and timely and meaningful evaluation and feedback for reinforcement.

Professionalism beyond medical school: an educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.

Fellows' in intensive care medicine views on professionalism and how they learn it

INTRODUCTION

The emphasis on the importance of professionalism in a recent CoBaTrICE-IT paper was impressive. However, insight into the elements of professionalism as perceived relevant for intensivists from the fellows' view, and how these are taught and learned, is limited.

OBJECTIVES AND METHODS

A nationwide study was performed in 2007-2008. All ICM fellows (n = 90) were sent a questionnaire containing the following questions regarding training in professionalism (7-point Likert scale (1 = very inadequate, 7 = very adequate)): which are the elements perceived to be important in intensivists'' daily practice (38 items, cat. I)? Which methods of learning and teaching are recognised (16 items, cat. II)? Which methods of teaching and learning are considered especially useful (16 items, cat. III)? Finally, the perceived quantity and quality of formal and informal learning methods, as well as the responsible organisational body was studied. Data were analysed using SPSS 15.0.

RESULTS

Response was 75.5 % (n = 68), mean age 34 years. Regarding Elements, scores on virtually all items were high. The factor 'striving for excellence' explained half the variance. Two other aspects, 'Teamwork' and 'Dealing with ethical dilemmas', were identified. Regarding Methods, three dimensions, 'formal curriculum'', 'private and academic experiences' and 'role modelling', proved important. The factor 'formal curriculum' explained most of the variance. Regarding Usefulness the same factors, now mainly explained by the factor Private and academic experiences, emerged with variance. In both categories the items 'observations in daily practice' and 'watching television programmes like ER and House' were the highest- and lowest-scoring items (5.99 and 5.81, and 2.69 and 2.49, respectively). Mean scores regarding the quantity of formal and informal teaching were 4.06 and 4.58 (range 1.841 and 1.519). For the quality of teaching, the figures were 4.22 and 4.52 (range 1.659 and 1.560, respectively). 54 suggestions for improvement of teaching were documented. The need for some form of formal teaching of professionalism aspects as well as for feedback was most frequently mentioned (n = 19 and 16). The local training centres are considered and should remain pivotal for teaching professionalism issues (n = 17 and 28).

CONCLUSIONS

Almost all elements of professionalism were considered relevant to intensivists' daily practice. Although formal teaching methods regarding professionalism aspects are easily recognised in daily practice, learning by personal experiences and informal ways quantitatively plays a more important, and more valued role. Qualitative comments, nevertheless, stress the need for providing and receiving (solicited and unsolicited) feedback, thereby requesting expansion of formal teaching methods. The local training centres (should continue to) play a major role in teaching professionalism, although an additional role for the (inter)national intensive care organisations remains.

Teaching and learning professional behavior in practice

This paper is the fourth article in a series on Professionalism and provides an overview of current methods used for teaching and learning about professionalism. The questions "whether" and "how" professionalism can be placed in the formal medical school curricula are addressed, and the informal learning related to professionalism reviewed.

Doctors in acute and longitudinal care specialties emphasise different professional attributes: implications for training programmes

OBJECTIVES

Organised medicine mandates that professionalism be taught during specialty training. This study's primary objective was to determine the relative importance that doctors in different specialties place on different attributes of a medical professional.

METHODS

Attending staff and resident doctors in acute care (anaesthesia, emergency medicine, surgery) and longitudinal care (internal medicine, psychiatry) specialties at a large academic hospital completed an anonymous, web-based survey. The forced-choice format required respondents to narrow down 25 professional attributes to three. The main outcome measure was the number of doctors in the two specialty groups who chose one or more attributes in each of six underlying categories.

RESULTS

Almost two-thirds of respondents in both groups chose Moral and Ethical attributes. Significantly more longitudinal than acute care doctors chose Relationships with Patients attributes (76% versus 58%) and Communication Skills attributes (28% versus 18%), whereas significantly more acute care doctors chose Clinical Competence attributes (44% versus 29%). Specialty group was more important in choice of professional attributes than gender or position as a resident or attending staff doctor.

CONCLUSIONS

Most respondents chose attributes that the literature and organised medicine define as core elements of medical professionalism. The differences between specialty groups suggest that attributes in the Relationships with Patients and Communication Skills categories be emphasised for trainees in acute care specialties, and attributes in the Clinical Competence category be emphasised for trainees in longitudinal care specialties.

Learning professionalism: perspectives of preclinical medical students

PURPOSE

To identify and examine how students respond to and engage with formal professionalism teaching strategies, and what factors outside the formal curriculum may influence professional development.

METHOD

Individual semistructured interviews were conducted with 56 students completing the preclinical curriculum at the University of Washington School of Medicine in 2004 and 2005. Interviews were recorded, transcribed, and analyzed using qualitative methods.

RESULTS

Students identified role modeling as an important modality for learning professionalism, even during their preclinical years. Role models included classroom faculty and peers, in addition to physicians in clinical settings. Small-group discussions and lectures helped some students identify and analyze the professional behaviors they observed, but they elicited negative responses from others. Students believed their professionalism derived from values, upbringing, and experiences prior to medical school. Some students reflected on their evolving professionalism while working directly with patients.

CONCLUSIONS

Medical schools should ensure that students are exposed to excellent role models-ideally, faculty who can articulate the ideals of professionalism and work with students longitudinally in clinical settings. Lectures about professionalism may alienate rather than inspire students. Students' premedical experiences and values influencing professionalism should be acknowledged and appreciated. Bedside teaching and reflection on students' inner experience as they begin to work directly with patients deserve further exploration as opportunities to teach professionalism.

Walking a mile in their patients' shoes: empathy and othering in medical students' education

One of the major tasks of medical educators is to help maintain and increase trainee empathy for patients. Yet research suggests that during the course of medical training, empathy in medical students and residents decreases. Various exercises and more comprehensive paradigms have been introduced to promote empathy and other humanistic values, but with inadequate success. This paper argues that the potential for medical education to promote empathy is not easy for two reasons: a) Medical students and residents have complex and mostly unresolved emotional responses to the universal human vulnerability to illness, disability, decay, and ultimately death that they must confront in the process of rendering patient care b) Modernist assumptions about the capacity to protect, control, and restore run deep in institutional cultures of mainstream biomedicine and can create barriers to empathic relationships. In the absence of appropriate discourses about how to emotionally manage distressing aspects of the human condition, it is likely that trainees will resort to coping mechanisms that result in distance and detachment. This paper suggests the need for an epistemological paradigm that helps trainees develop a tolerance for imperfection in self and others; and acceptance of shared emotional vulnerability and suffering while simultaneously honoring the existence of difference. Reducing the sense of anxiety and threat that are now reinforced by the dominant medical discourse in the presence of illness will enable trainees to learn to emotionally contain the suffering of their patients and themselves, thus providing a psychologically sound foundation for the development of true empathy.

Is there hardening of the heart during medical school?

PURPOSE

To determine whether vicarious empathy (i.e., to have a visceral empathic response, versus role-playing empathy) decreases, and whether students choosing specialties with greater patient contact maintain vicarious empathy better than do students choosing specialties with less patient contact.

METHOD

The Balanced Emotional Empathy Scale was administered at the beginning of each academic year at the University of Arkansas for Medical Sciences for four classes, 2001-2004. Students also reported their gender and specialty choice. Specialty choice was classified as core (internal medicine, family medicine, obstetrics-gynecology, pediatrics, and psychiatry) or noncore (all other specialties).

RESULTS

Vicarious empathy significantly decreased during medical education (P < .001), especially after the first and third years. Students choosing core careers had higher empathy than did those choosing noncore careers. Men choosing core careers initially had empathy exceeding population norms, but their empathy fell to be comparable with that of norms by the end of their third year. The empathy of men choosing noncore careers was comparable with that of norms. Women choosing core careers had empathy scores comparable with those of norms, but the scores of women choosing noncore careers fell below those of the norms by their second year.

CONCLUSIONS

The findings suggest that undergraduate medical education may be a major determinant differentially affecting the vicarious empathy of students on the basis of gender and/or specialty choice. The greatest impact occurred in men who chose noncore specialties. The significant decrease in vicarious empathy is of concern, because empathy is crucial for a successful physician-patient relationship.

AMEE Guide no. 34: Teaching in the clinical environment

Teaching in the clinical environment is a demanding, complex and often frustrating task, a task many clinicians assume without adequate preparation or orientation. Twelve roles have previously been described for medical teachers, grouped into six major tasks: (1) the information provider; (2) the role model; (3) the facilitator; (4) the assessor; (5) the curriculum and course planner; and (6) the resource material creator (Harden & Crosby 2000). It is clear that many of these roles require a teacher to be more than a medical expert. In a pure educational setting, teachers may have limited roles, but the clinical teacher often plays many roles simultaneously, switching from one role to another during the same encounter. The large majority of clinical teachers around the world have received rigorous training in medical knowledge and skills but little to none in teaching. As physicians become ever busier in their own clinical practice, being effective teachers becomes more challenging in the context of expanding clinical responsibilities and shrinking time for teaching (Prideaux et al. 2000). Clinicians on the frontline are often unaware of educational mandates from licensing and accreditation bodies as well as medical schools and postgraduate training programmes and this has major implications for staff training. Institutions need to provide necessary orientation and training for their clinical teachers. This Guide looks at the many challenges for teachers in the clinical environment, application of relevant educational theories to the clinical context and practical teaching tips for clinical teachers. This guide will concentrate on the hospital setting as teaching within the community is the subject of another AMEE guide.

Mission Statement Day: the impact on medical students of an early exercise in professionalism

BACKGROUND

The development of professional attitudes in medical students is an important aspect of medical education.

AIMS

This qualitative study describes medical students' experience of Mission Statement Day.

METHOD

The study was conducted using focus groups and key informant interviews. Thematic analysis identified key words, phrases, and concepts. The data was condensed into major themes and key quotes were identified to illustrate each theme.

RESULTS

The process of creating a Mission Statement was more important than the Mission Statement. Three themes were identified; the central role of patients, bonding and group formation, and student ownership and valuing of the Mission Statement. Patient involvement was critical to exploring the disease and illness experience, and to stimulating discussion about compassion and professional relationships. Role modelling by faculty highlighted the value placed on this experience by the medical school. The experience was memorable, prompting the medical students to reflect on their personal values and their decision to enter medical school.

CONCLUSIONS

Creation of a Mission Statement is a powerful way to introduce students to their future professional role, identify their values, and begin to develop a sense of professional identity. This memorable experience could be expanded to help students continue their professional growth.

The influence of personal and environmental factors on professionalism in medical education

BACKGROUND

Professionalism is a critical quality for physicians to possess. Physician professionalism has received increased attention in recent years, with many authorities suggesting that professionalism is in decline. An understanding of the factors contributing to professionalism may allow the development of more effective approaches to promoting this quality in medical education.

DISCUSSION

We propose a model of personal and environmental factors that contribute to physician professionalism. Personal factors include distress/well-being, individual characteristics, and interpersonal qualities. Environmental factors include institutional culture, formal and informal curricula, and practice characteristics. Promotion of professionalism requires efforts directed at each of these elements.

SUMMARY

One responsibility of medical education is to foster the development of professionalism among its learners. Both personal and environmental factors play a role in physician professionalism. Accordingly, institutions should consider these factors as efforts to promote physician professionalism evolve.

Teaching and Assessing Professionalism in Ophthalmology Residency Training Programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs teach and assess new competencies including professionalism. This article reviews the literature on medical professionalism, describes good practices gleaned from published works, and proposes an implementation matrix of specific tools for teaching and assessing professionalism in ophthalmology residency. Professionalism requirements have been defined by the ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching, role modeling, and assessing the competency of professionalism are important tasks in managing the ACGME mandate. Future work should focus on the field testing of tools for validity, reliability, feasibility, and cost-effectiveness.