Creating a Framework for Medical Professionalism: An Initial Consensus Statement From an Arab Nation

Transforming Professionalism Education in Clerkships: A Student-Driven Approach Utilizing The Hidden Curriculum

Introduction

Professionalism, influenced by regional context and societal values, is essential in doctor-patient relationships, patient experiences, and clinical outcomes. However, formal education alone fails to cultivate professionalism effectively. Research highlights the hidden curriculum's detrimental impact on medical students' professionalism. Nonetheless, strategies to teach professionalism in specific curriculum areas and to counteract hidden curricula, particularly for clinical clerkships, remain underexplored. This study evaluates a structured, student-led professionalism training program in a clerkship.

Methods

Over one year, we implemented and replicated an educational intervention on professionalism in four emergency medicine clerkship groups. Grounded in constructivist and transformative learning theories, the intervention aimed to enhance students' reflective capacities by addressing the hidden curriculum. It included briefing sessions on professionalism models and student-led discussions on clinical cases encountered to uncover implicit lessons. Students' understanding was reinforced through anonymous self- and peer assessments of professionalism traits. The impact was evaluated qualitatively through inductive thematic analysis of student reflections and quantitatively through student feedback based on the Kirkpatrick model.

Results

The training received highly positive evaluations from students. Quantitative analysis showed significant score increases in knowledge and ability (using the Wilcoxon Signed Rank Test). Students demonstrated the ability to reflect on the hidden curriculum and highlighted three key themes: professional attributes, sociocultural context, and system-level factors. Subthemes included communication, empathy, learning commitment, cultural competence, hierarchy, and family engagement.

Discussion

This study presents a practical clerkship professionalism training model demonstrating that regular case-based discussions and anonymous self- and peer assessments help students identify and reflect on professional behaviors within the hidden curriculum.

Professionalism-training in undergraduate medical education in a multi-cultural, multi-ethnic setting in the Gulf Region: an exploration of reflective essays

BACKGROUND

Despite the established need to prioritize professionalism-training in developing future physicians, very few medical programs in the Gulf Region embed in their curricula discrete contextualized courses aimed at developing the corresponding competencies, while fostering self-directed learning. This study aims at exploring the perception of undergraduate medical students in a multi-cultural, multi-ethnic setting regarding their understanding of, and personal experience with professionalism through their engagement with the content of an innovative curriculum-based professionalism course, offered at a Medical School in Dubai, United Arab Emirates.

METHODS

The study used a qualitative phenomenological research design. Out of 33 students, 29 students had submitted reflective essays. The content of these essays was inductively analyzed following a six-step framework for conducting thematic analysis. The framework's steps include familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.

FINDINGS

The inductive qualitative analysis generated the Professionalism Learning Journey model. This conceptual model includes four interconnected themes: Awareness, Acknowledgement, Realization, and Application. The generated model depicts the trajectory that the learners appear to experience while they are engaging with the content of the course.

CONCLUSION

Integrating a professionalism-training course into an undergraduate medical curriculum is likely to be positively appraised by the learners. It raises their awareness, enables them to value the subject matter and the sophistication of its application, and empowers them to put into practice the taught principles, on an individual basis and collectively. This is especially true when the course is entrenched in constructivism experiential learning theory and designed to foster self-directed learning. The introduced conceptual model, in conjunction with the innovative professionalism-training course curriculum, can serve as a template for other competencies and other schools.

Paradigms unfolded - developing, validating, and evaluating the Medical Education e-Professionalism framework from a philosophical perspective

In order to ensure a strong research design, literature stresses the adoption of a research paradigm that is consistent with the researcher's beliefs about the nature of reality. In this article we provide an overview of research paradigm choices in relation to the creation of a Medical Education e-Professionalism (MEeP) framework discussing the research design, research methods, data collection and analysis to enhance the transparency of our previously published research. The MEeP framework was conceived to help Health Care Professionals (HCPs) safeguard the construct of professionalism in the digital context. This entire process was heavily informed by wider readings and deliberations of published literature on e-professionalism. Although the MEeP framework research journey has been published, the paradigms approach was not discussed in any detail. Considering that one of the duties of medical educator is to balance the service and science by bringing the theoretical underpinnings of one's research to public attention and scrutiny so as to nullify the notion of 'weak' research. We were compelled to unfold this paradigm story of the MEeP framework in a detailed manner. In an effort to make our research both robust and effective, this study portrays a philosophical approach to guide future research designs and methodological choices by detailing our rationale for pragmatism as a choice of paradigm.

What are the Attitudes of Medical Students at Jazan University Toward Professionalism?

PURPOSE

We assessed the attitudes of Jazan University medical students toward professionalism and evaluated the associations of those attitudes with demographic factors.

MATERIALS AND METHODS

Seven hundred ninety-seven respondents (88.85% response rate) out of 898 students who were invited to this study (50.7% were men and 49.3% were women) were studied by their response to the Learner's Attitude of Medical Professionalism Scale (LAMPS) that assess their level of agreement with 28 items, each reflecting a single professionalism competency within the subscales of Altruism, Excellence, Duty/Accountability, Honor/Integrity, and Respect for Others.

RESULTS

Of 797 respondents (88.85% response rate), 50.7% were men and 49.3% were women. Subscales with high agreement scores were Excellence (median, 21.0; range, 6-30) and Duty/Accountability (median, 21.0; range, 7-35). Subscales with slightly lower agreement scores were Respect for Others (median, 15.0; range, 5-25), Altruism (median, 15.0; range, 5-25), and Honor/Integrity (median, 12.0; range, 5-25). No sex differences were observed for most subscales; however, men gave higher agreement scores on the Excellence subscale, and compared with year 3 respondents (preclinical phase), year 6 respondents (clinical phase) gave higher agreement scores on the Excellence, Altruism, and Respect for Others subscales.

CONCLUSION

Overall, medical students at Jazan University indicated high agreement with all attitudes to professionalism subscales on the LAMPS.

The Role of Religious Culture in Medical Professionalism in a Muslim Arab Society

Purpose

Calls have been made to integrate concepts and practices derived from Muslim culture into medical professionalism in Muslim societies. Little is known about how these religious cultural concepts (RCCs) influence medical practice and education. This study explored the influence of RCCs on medical professionalism in Saudi Arabia.

Methods

This was a qualitative study that implemented a constructivist, grounded theory approach. Semi-structured interviews about RCCs and medical professionalism were conducted with 15 Saudi physicians at a single academic medical center. Purposive sampling was used to recruit participants of different genders, generations, and specialties. Data collection and analysis were iterative. A theoretical framework was formulated.

Results

Key findings: (i) the role of RCCs in medical professionalism is perceived to be constantly evolving due to the evolution of societal interpretations of RCCs; (ii) participants described applying two standards to judge what is professional: a medical standard and a religious cultural standard. Participants shifted between these two standards variably and non-linearly. This variable shifting altered the values shaping medical professionalism, at times unpredictably.

Discussion

Academic Saudi physicians argued against assuming a stable traditional interpretation of RCCs, emphasized the evolving contribution of RCCs to medical professionalism, and indicated that the process of merging religious cultural and medical standards in medical practice is variable and may alter medical practice values. Therefore, these physicians perceived RCCs to be useful as supplements to but not as a backbone for medical professionalism. Careful consideration of the potential impact of RCCs on the values of medical professionalism is warranted.

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.

Truth Disclosure at the End of Life: A Qualitative Study of Internal Medicine Residents in the United Arab Emirates

BACKGROUND

Respect for patient autonomy has become the guiding biomedical ethical tenet in the West; yet, moral values are contextual and culturally relevant. In the collectivist society of the Middle East, families and physicians have historically believed that concealing truth about a terminal illness is more ethical and compassionate. Recent studies reveal a trend toward truth disclosure.

OBJECTIVE

To gain insight into resident experiences with, and barriers to, truth disclosure in terminally ill patients in the United Arab Emirates (UAE).

METHODS

Focus group interviews were conducted with first through fourth year internal medicine residents and recent graduates at two large academic medical centers in the UAE. Qualitative thematic content analysis was used to identify themes related to communication and truth telling in end-of-life care.

RESULTS

Residents revealed that non-disclosure of medical information in serious illness is a common practice in UAE hospitals. Barriers to truth telling include family objection, deficits in medical training, and inconsistently implemented institutional guidelines.

CONCLUSION

Educational and policy interventions are needed to improve physician-patient communication, decrease patient-family-physician tension, and alleviate trainee moral distress.

When patient-centred and family-centred approaches clash: Taiwanese health professions students' patient autonomy dilemmas

The main purpose of the study was to examine whether health professions students in Taiwan who study in different programmes experience similar patient autonomy-related professionalism dilemmas caused by disconnections between school and clinical culture. To investigate this issue, we draw specifically on situated learning theory and its cultural concept to examine their professionalism dilemma narratives that were collected through interviews. Of the 79 interviewed students, nearly half of them experienced patient autonomy dilemmas caused by conflicts between school and clinical culture, which have significant negative impacts on their learning and emotional wellbeing. Four major types of patient autonomy-related dilemmas emerge from the data. It was also found that when school culture and clinical culture clash, the latter has a greater influence on students. Thus, the study argues that Taiwanese students' frequent encounters with patient-autonomy dilemmas highlight the challenges faced by health professions students in transferring knowledge between school and clinical cultures, and clinical culture has a more powerful influence on their behaviour and clinical decision making. This phenomenon should be taken into account when organizing health professions education.

Perception of Saudi Undergraduate Students Towards Professionalism in Medicine

Objectives

Professionalism has garnered immense attention in medical education due to increased societal accountability and focus on excellence in healthcare. However, less attention has been given to identifying attitudes about professionalism in medical students who are the future advocates of the healthcare system. This study aimed to assess perceptions of Saudi undergraduate medical students towards professionalism.

Methods

A cross-sectional survey was carried out among second and sixth year students of the College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, in September 2018. A self-administered professionalism questionnaire was anonymously completed. Students were asked to provide their level of agreement with 18 survey items using a 5-point Likert scale.

Results

Overall, 288 students participated in the study (males: 49.3% and females: 50.7%), with a response rate of 90%. The median professionalism score was high (71.0; range: 64–76) regardless of age, gender or level of education. Similar high scores were noted in the following subscales: Excellence, 20.0 (range: 18–21); Respect for Others, 17.0 (14–18); Altruism, 12.0 (10–13); Duty, 8.0 (7–9); Accountability, 7.0 (6–8) and Honour and Integrity, 8.0 (7–10). No gender differences were observed in the majority of subscales. However, males demonstrated higher scores in the Duty subscale (males: 9.0 versus females: 8.0; P = 0.026).

Conclusion

Medical students demonstrated high professionalism scores. Future studies are needed to assess the impact of the course curriculum on their level of professionalism over time.

Medical education in the United Arab Emirates: Challenges and opportunities

Medical education (ME) in the United Arab Emirates (UAE) has a relatively short history that begins with the inception of the UAE almost 50 years ago. The UAE has made great strides in widening access to ME through the rapid implementation of national agendas aimed at advancing healthcare and expanding higher education, in addition to the presence of a strong infrastructure for privatization and business development. While progress is being made at all levels of ME, complex challenges for both undergraduate and postgraduate ME remain. Going forward, issues of standardization, quality, sustainability of academic and healthcare workforces, and research must continue to be addressed.

Preclerkship medical students' perceptions of medical professionalism in the College of Medicine-University of Sharjah: A vision to sustain success in medical education

INTRODUCTION

Professionalism is an essential theme in both undergraduate and postgraduate medical education. The current study aimed to assess the preclerkship medical students' perception on medical professionalism.

METHODS

A cross-sectional qualitative study using the critical incident technique was conducted at the University of Sharjah in the United Arab Emirates (UAE). An online survey was sent to 300 medical students (years 1-3). Participants were asked to describe an official doctor-patient encounter that they have experienced in a health-care setting and to highlight the professional behaviors in that encounter. They were then requested to list the top five characteristics of a professional doctor. Thirty (10%) medical students responded to the study; only 13 reported real incidents. The responses were independently reviewed by the authors. The descriptions of the professional attitudes were grouped according to the six domains of professionalism defined by the American Board of Internal Medicine (ABIM) Physicians Charter and then plotted against the nine domains of medical professionalism published in the UAE Consensus Statement.

RESULTS

The most common professional behaviors reported were patience, honesty, respect, and patient care. The participants addressed all six domains of professionalism described by the ABIM physicians charter (altruism, accountability, duty , excellence, honor and integrity, and respect for others) and all the domains of medical professionalism published in the UAE Consensus Statement, except for "commitment to advocacy" and "commitment to education" domains.

CONCLUSION

Preclerkship medical students had an insight about the professional behaviors needed from doctors before formal teaching about professionalism in the curriculum.

Exploration of constructs of professionalism identified in the ABIM framework as perceived by the faculty fitting the Pakistani context

OBJECTIVE

Domains of professionalism are well-described in the literature. Examining the elements of Professionalism in the local context have received less attention from education experts. The aim of the study was to explore the construct of professionalism as perceived by the faculty that fitted the Pakistani context identified in the ABIM framework of professionalism.

METHODS

This qualitative ethnographic research was conducted involving nine participants from Islamic International Medical College in Riphah University Islamabad. A four hours Focus Group Discussion was undertaken to explore the views of the faculty. The focus group session was audiotaped, transcribed and technique of triangulation was employed. Shortened meaningful unit (SMU) were identified from the transcribed data and analyzed to make codes for themes for the behaviors. Forty-six meaningful units were categorized and codes were identified. The themes were identified under the domains of the ABIM frameworks for the Pakistani context.

RESULTS

The participants listed 2-8 elements for each domain of the framework describing the professional conduct which lead to 140 shortened meaningful units. These were organized into 46 higher order codes.

CONCLUSIONS

The study concludes that that ABIM framework can be used to build consensus regarding the domains of professionalism. No difference was found cross contextually regarding the domains of ABIM framework of professionalism.

Comparison of the Professionalism Behaviours of Medical Students from Four GCC Universities with Single-gender and Co-educational Learning Climates

Background:

Medical professionalism is a multi-dimensional construct that is viewed differently across institutions. Such variations might be related to diverse cultural and societal characteristics of learners and faculty.

Objectives:

This study determined whether differences exist between proposed sanctions for a one-time academic integrity infraction associated with unprofessional behaviors. We selected four medical schools with either single-gender or co-educational learning environments in the Gulf Cooperation Council (GCC) countries.

Methods:

The 34-statement Dundee Polyprofessionalism Inventory I was disseminated to all medical students across years in selected institutions. Descriptive and inferential statistical analyses were conducted, and median scores were used to determine the respondents’ proposed sanctions.

Results:

Of the 1941 invitees, 1313 students responded (response rate of 68%). Significant similarity, as recorded by median sanction scores was recorded for 21 (62%) of the 34 inventory items from two medical schools. However, significant differences of one level of difference between all the median sanction scores for single-gender and co-educational students were found for 32% of inventory items. In co-educational schools, males were stricter than females for 9% and seniors were stricter than juniors for 12% of the inventory items. In contrast, in single-gender schools, females were stricter than males for only 6% of the inventory and seniors were more lenient than juniors for another 6% of the inventory.

Conclusions:

This study reports significant congruence and some differences in medical students’ perceptions of unprofessional behaviors. Educators are urged to develop a unified framework for enforcing sanctions to unprofessional behaviors.

Organizational Factors Contributing to Incivility at an Academic Medical Center and Systems-Based Solutions: A Qualitative Study

PURPOSE

A rise in incivility has been documented in medicine, with implications for patient care, organizational effectiveness, and costs. This study explored organizational factors that may contribute to incivility at one academic medical center and potential systems-level solutions to combat it.

METHOD

The authors completed semistructured individual interviews with full-time faculty members of the Department of Medicine (DOM) at the University of Toronto Faculty of Medicine, Toronto, Ontario, Canada, with clinical appointments at six affiliated hospitals, between June and September 2016. They asked about participants' experiences with incivility, potential contributing factors, and possible solutions. Two analysts independently coded a portion of the transcripts until a framework was developed with excellent agreement within the research team, as signified by the Kappa coefficient. A single coder completed analysis of the remaining transcripts.

RESULTS

Forty-nine interviews with physicians from all university ranks and academic position descriptions were completed. All participants had collegial relationships with colleagues but had observed, heard of, or been personally affected by uncivil behavior. Incivility occurred furtively, face-to-face, or online. The participants identified several organizational factors that bred incivility including physician nonemployee status in hospitals, silos within the DOM, poor leadership, a culture of silence, and the existence of power cliques. They offered many systems-level solutions to combat incivility through prevention, improved reporting, and clearer consequences.

CONCLUSIONS

Existing strategies to combat incivility have focused on modifying individual behavior, but opportunities may exist to reduce incivility through a greater understanding of the role of health care organizations in shaping workplace culture.

Pushing chronic care forward in Abu Dhabi by identifying priorities and addressing barriers: a modified Delphi technique

OBJECTIVE

This study aimed to elucidate the top five key priorities and barriers to chronic care in the health system of Abu Dhabi, United Arab Emirates (UAE).

DESIGN

A modified Delphi study was performed to reach consensus on priority areas and barriers to the development of the Chronic Care Model in the health system of Abu Dhabi. Individual wireless audience response devices (keypads) linked to a computer were used to reduce 28 priorities and 20 barriers to the top five during three iterative rounds over three consecutive days.

SETTING

Chronic care services for patients with diabetes, cardiovascular diseases and cancer, in both private and publicly funded healthcare services in the emirate of Abu Dhabi.

PARTICIPANTS

A purposive sample of 20 health systems' experts were recruited. They were front-line healthcare workers from the public and private sector working in the delivery of care for patients with diabetes, cardiovascular diseases and cancer.

RESULTS

The 'overall organizational leadership in chronic illness care' was ranked as the most important priority to address (26.3%) and 'patient compliance' was ranked as the most important barrier (36.8%) to the development of the Chronic Care Model.

CONCLUSIONS

This study has identified the current priorities and barriers to improving chronic care within Abu Dhabi's healthcare system. Our paper addresses the UAE's 2021 Agenda of achieving a world-class healthcare system, and findings may help inform strategic changes required to achieve this mission.

A time for new north-south relationships in global health

The modern concept of globalization in health care and clinical research often carries a positive message for the “Global South” nations of Africa, South America and Southeast Asia. However, bioethical abuse of participants in clinical trials still exists in the Global South. Unethical studies directed by the “Global North”, formed by the medically advanced nations in North America, Western Europe and Japan, have been hugely concerning. The issue between the Global North and South is a well-recognized socioeconomic phenomenon of globalization. Medical exploitation has its roots in the socioeconomic interactions of a postcolonial world, and solutions to reducing exploitation require a deeper understanding of these societal models of globalization. We explore the fundamental causes of imbalance and suggest solutions. Reflecting on the globalization model, there must be an effort to empower the Global South nations to direct and govern their own health care systems efficiently on the basis of equality.