Beruflich Dokumente
Kultur Dokumente
Abstract
Purpose Results Conclusions
To identify and examine how students Students identified role modeling as an Medical schools should ensure that
respond to and engage with formal important modality for learning students are exposed to excellent role
professionalism teaching strategies, and professionalism, even during their models—ideally, faculty who can
what factors outside the formal preclinical years. Role models included articulate the ideals of professionalism
curriculum may influence professional classroom faculty and peers, in addition and work with students longitudinally
development. to physicians in clinical settings. Small- in clinical settings. Lectures about
group discussions and lectures helped professionalism may alienate rather than
some students identify and analyze the inspire students. Students’ premedical
Method professional behaviors they observed, experiences and values influencing
Individual semistructured interviews professionalism should be acknowledged
but they elicited negative responses
and appreciated. Bedside teaching and
were conducted with 56 students from others. Students believed their
reflection on students’ inner experience
completing the preclinical curriculum at professionalism derived from values,
as they begin to work directly with
the University of Washington School of upbringing, and experiences prior to
patients deserve further exploration as
Medicine in 2004 and 2005. Interviews medical school. Some students reflected opportunities to teach professionalism.
were recorded, transcribed, and on their evolving professionalism while
analyzed using qualitative methods. working directly with patients. Acad Med. 2009; 84:574–581.
I n recent years, medical education taught have emerged: (1) role models are professionalism education untapped by
organizations and accrediting bodies have the primary influence on students’ educators.
focused increasingly on professionalism professional development,8 –10 (2)
The objective of the qualitative analyses
in medical training.1– 4 Professionalism is activities in which trainees are explicitly
described here was to explore students’
now a required competency across the taught principles of professionalism are
perceptions about how they had learned
continuum of undergraduate,5 graduate,6 an important adjunct to relying professionalism by the end of their
and continuing medical education.7 As exclusively on role modeling,11–13 (3) preclinical curriculum. Our results offer
professionalism has been incorporated observing negative role models in patient educators insight into how and whether
across these curricula, consistent themes care is inevitable, but having faculty formal and informal curricula engage
regarding how professionalism should be available to students to debrief these students.
events may mitigate deleterious
effects,14 –16 and (4) to truly promote
Professionalism in the Preclinical
Dr. Baernstein is associate professor, Department professionalism in our trainees, medical
Curriculum
of Medicine, University of Washington School of schools must hold the entire faculty to
Medicine, Seattle, Washington, and a member of the At the University of Washington School of
the highest professional standards.2,9,11
college faculty.
Medicine, our approach to teaching
Dr. Amies Oelschlager is assistant professor, Although many schools have reported professionalism in the preclinical
Department of Obstetrics and Gynecology, University curriculum combines formal and informal
of Washington School of Medicine, Seattle, on strategies for explicitly teaching
Washington, and a member of the college faculty. professionalism,17–25 how students elements. The formal professionalism
respond to, learn from, and engage curriculum includes lectures, panels, small-
Dr. Chang is assistant professor, Department of
Medicine, University of Washington School of with these strategies has rarely been group discussions, written reflections, and
Medicine in Seattle, Washington, and a member of studied in depth.26 It is important ceremonies (Table 1). Students receive an
the college faculty.
to identify the most relevant and explicit set of behavioral expectations called
Ms. Wenrich is affiliate instructor, Department of successful strategies from the learners’ professionalism benchmarks. All second-year
Medical Education and Biomedical Informatics, and
perspective because learner buy-in is students must complete and pass a six-
director of special projects and advisor to the dean, station objective structured clinical
University of Washington School of Medicine, essential to engaging students in a topic
Seattle, Washington. examination (OSCE) before progressing to
that may be perceived as abstract or
clerkships. One OSCE station specifically
Correspondence should be addressed to Dr. extraneous to the scientific curriculum.
Baernstein, Harborview Medical Center, 325 addresses a professionalism issue.
Examining students’ perceptions of how
Ninth Avenue, Box 359702, Seattle, WA 98104;
telephone: (206) 744-3263; fax: (206) 744-3563; they learned professionalism may also The informal professionalism curriculum
e-mail: (abaer@u.washington.edu). identify potentially rich sources of emerges through student contact with
Preclinical
year Lectures/panels* Small-group discussions† Written reflections‡ Ceremony Evaluation
575
Professionalism
Professionalism
faculty, physicians, or peers, often in the mentor has an opportunity to discuss evaluation. Questions assessed multiple
clinical contexts. In our undergraduate the principle of responsibility and how domains of the curriculum, including the
setting, patient contact occurs in one team member’s actions affect teaching of professionalism. Every
individual interviews during the first others. Mentors receive explicit faculty participant was asked six questions
year. Each first-year student interviews development on identifying and specifically addressing professionalism.
seven patients, focusing on patients’ addressing professionalism issues in These questions included the student’s
social history and experience of illness. small-group and patient-related settings. definition of professionalism, self-
Additional patient contact often occurs in perceived influences on professionalism,
the summer between the first and second We were interested in students’ perceptions the college faculty and college group’s
years, when more than half of students of the formal and informal preclinical influence on professionalism, and
work with community physicians for four professionalism curricula. In 2004 and professional and unprofessional
weeks. Patient contact also occurs during 2005, students were being interviewed
behaviors observed.
preceptorships, in which students work as part of an ongoing curriculum
with a physician for at least one quarter. improvement process at the University of
Preceptorships are offered during the first Washington School of Medicine.27 Part of Data collection, analysis, and
and second years; all preclinical students each interview focused specifically on our interpretation
are required to work with at least one professionalism curriculum, which shares In-depth, face-to-face, semistructured
preceptor. many components with curricula interviews were conducted by nonclinical
elsewhere.17–22,24,25 Because most medical education faculty with no
During the second year, patient contact institutions continually modify or develop
supervisory relationship to students.
occurs in the context of the colleges new curricula and may look to the
Interviews, conducted in confidential
program, in which students receive literature for guidance,29 our students’
settings and approximately 45 minutes in
instruction in clinical skills (interviewing, reactions to various strategies for teaching
physical exam, clinical reasoning, oral professionalism may be relevant to other length, were audiotaped. Students were
and written presentations) and schools. We present the results of our not identified by name in the interview.
professionalism from 1 of 30 college analyses of students’ interview responses
mentors. These faculty, selected in a about our professionalism curriculum to Students’ responses were later
competitive process, are given release assist educators seeking to refine strategies transcribed, and all potential identifiers
time for their teaching and mentoring for teaching professionalism to preclinical were removed. For the purpose of our
activities, and they mentor a consistent students. analyses, we used portions of the
group of students in each class from transcripts relevant to professionalism.
enrollment to graduation.27,28 Each
mentor meets weekly with his or her Method All members of our research team
group of six second-year students in an Participants initially reviewed a common set of 12
inpatient setting. Two students each week interviews and, from this common
interview and examine hospitalized patients A convenience sample of second-year review, developed preliminary domains
under their mentor’s supervision. These students completed interviews in 2004
and categories within domains. Then,
students then present their patients at the and 2005 as part of the school of
two researchers (A.B. and either A.A.O.,
bedside to the mentor and the other five medicine’s internal curricular
T.A.C., or M.D.W.) independently coded
students. By the end of the year, each improvement process. All second-year
medical students were invited via e-mail each of the 56 transcripts using these
student has interviewed, examined, and common domains and categories. New
given a bedside presentation on six to participate near the end of the 2003–
2004 and 2004 –2005 academic years, domains and categories that emerged
hospitalized patients and has observed and were discussed and added during the
discussed an additional 30 patients. with the goal of identifying 30 students
for interviews and completing interviews coding process. Coding discrepancies
with at least 25 students per year in 2004 were reconciled by discussion and
College mentors explore professionalism consensus. Analysis oversight was
issues that arise at the bedside and in and 2005. Students were informed that
the purpose of the interview was to learn provided by an experienced qualitative
group dynamics with their students.
how the curriculum performs in order to researcher without direct clinical
These mentors, who participated in
make future improvements. Students exposure to the students (M.D.W.).
development of the professionalism
benchmarks described above, are were assured that their responses would
encouraged to refer to and reinforce be deidentified and were, therefore, In coding pairs we also identified,
these benchmarks in discussions of confidential. Each student received $50 reviewed, and discussed representative
professionalism with their students. For for participating. Our use of these data quotations. Quotations best exemplifying
example, a patient may express hostility for this study was approved by the domains or categories within domains
toward a student of a different race, University of Washington institutional were edited for length and flow, but the
allowing the mentor to explore the review board. text’s meaning was preserved. Numeric
principle of respect for all patients despite counts of domains and categories are
differences in values and to examine the Instrument presented in some cases to demonstrate
value of self-reflection in managing Interview questions were developed by a how frequently these topics were raised
physicians’ own emotional responses. core team of medical education faculty by students. We calculated interrater
Similarly, if a student is consistently late, with expertise in qualitative research and reliability using all transcripts.
panels focused on professionalism had I just can’t stand it. It makes me want to “What I bring to medical school”:
a positive impact. Effects included run away. Noncurricular elements
“broadening my viewpoints” and Fifteen students (27%) mentioned their
learning “political pearls,” such as Some students commented that being
upbringing or personal values they
specific behaviors that improve lectured on concrete topics such as
brought to medical school as important
interprofessional relationships. Some appropriate dress was insulting. Yet,
influences on their emerging
students were very enthusiastic about students specifically identified
professionalism. Six additional students
lectures: inappropriate dress as an unprofessional identified physician relatives as
behavior they observed in peers. Several influences. Students’ comments about the
We had one guy talk on professionalism. students explicitly contrasted what peers
And I thought he was amazing! It just influence of upbringing are represented
really made me proud to enter the
should know with how some behave. by a few typical recurring statements: “I
profession that I am. I thought, “Oh, this think professionalism is a really hard
is great. This is teaching me how to better Small-group discussions. Students thing to teach,” “It’s intuitive,” and “It’s
myself and be a better doctor to my frequently cited formally organized how you were raised.”
patients.” small-group discussions as positive
learning experiences: Ten students noted that work experience
Another student articulated that although
prior to medical school influenced their
she learned professionalism from First and second year, you’re more professionalism, and two others
watching role models, explicit discussions worried about passing courses and
identified formative undergraduate
about professionalism were important to learning all the basic sciences material.
But when you talk to [clerkship] students experiences. Some students asserted that
interpret what she saw. When prompted
who can relate some specific situation professionalism was established by the
about whether role modeling or lectures
they were in, and the decisions people admission process, which weeded out
were more important, she replied,
made, or how they interacted with others, unprofessional students:
I think it’s a combination. I noticed my you get a much better sense of, “Okay,
this is what is meant by professionalism.” If you select a student body for a medical
mentor’s professionalism because I had
school, you’re looking for certain
been learning about it in lecture. I might
characteristics. And the chance that any
not have picked up on it, always, just with Of 44 students who identified their one of those individuals is going to go
him. college mentor as a positive role model, into a patient’s room and act
nearly half described discussions their unprofessionally is slim to none.
Several students believed lectures were mentor led as important in learning
important for other students, although professionalism, as distinct from “Learning on the job”: Experiential
not necessarily for them. Exploring observation alone. For example, learning
professionalism in lectures had a
Seven students (13%) described working
“preaching to the choir” element, with We would bring things up, and [our directly with patients as influencing their
interest only from those who believe they mentor] would say, “Well, this happened developing professionalism. One student
already embrace professionalism: to one of my students and this is how they
said, “You can have as many lectures as
handled it, and maybe I would do
People see that professionalism is coming something different.” It makes a big
you want, but there’s a big difference
up on the schedule and skip class. It really difference to talk about a situation between hearing about it and actually
disturbs me that they aren’t coming. I before it arises. After we discussed it, doing it and applying it for yourself.”
think the people who probably need to everybody felt more comfortable. I
learn the most are the ones that aren’t don’t know if they were necessarily Other students described how seeing
there. eager to discuss it, but they felt more patients at their preclinical stage felt like
prepared, after they had. play-acting but was valuable for learning
An equal number of students15 had professional behavior:
negative reactions to lectures and panels
about professionalism. Comments Other formal parts of the curriculum.
Just putting on a suit and going and
included No student specifically mentioned the acting like a doctor, eventually that
written reflections required in our formal reinforces the inner change and you start
I learn things by being in situations curriculum, but five students reported understanding little bits, [like] “Oops,
and experiencing or having things that they learned professionalism from that didn’t feel very appropriate, that
demonstrated for me. A lot of the class didn’t feel right. I shouldn’t have said
self-reflection or informal discussions
is just going to tune out and play games that” or “That felt good.” Just training as
on their computer, during that with family and friends. No student you go.
[professionalism] lecture. mentioned ceremonies, although when
students discussed “lectures,” this may I still feel when I put a stethoscope
have referred to speeches at these around my neck, like I’m playing dress
Several students felt that lectures and
up. Every time I go into clinic or the
panels “turned them off” to events. Three students reacted to the hospital, I am always acutely sensitive to,
professionalism: professionalism OSCE, commenting that “How am I supposed to behave?”
it was educational or spurred useful
What professionalism meant to me before
discussions, whereas two others
coming to medical school was exactly Discussion
what they say to us. What it means to me commented that the station was unfair or
now is just a lecture: “We’re going to tell inappropriately reduced professionalism In this qualitative research study, we
you how to act, before you ever mess up.” to “the one right answer.” examined in depth how students
responded to diverse strategies, both explored in the literature. This how they learned professionalism hinges
formal and informal, for imparting emphasizes the need for basic science on the importance that students place on
professionalism in a preclinical faculty to work in concert with experiences prior to medical school. This
curriculum. By asking students broad clinical faculty and medical school finding has been described elsewhere but
questions about how they learned administration to ensure that consistent only in brief.32,38 Many students said they
professionalism, we provided standards of professionalism are learned or inherited professionalism from
opportunities for students to describe demonstrated for and explicitly their upbringing, prior employment, or
sources outside our stated curriculum, promoted to students throughout their undergraduate education. To some
elucidating influences beyond curricular education. students, a formal professionalism
control. curriculum implied that faculty believed
Students perceived that they learned they lacked professionalism, engendering
Students’ responses to some strategies professionalism from their peers, a source resistance to the curriculum. To bridge
may not be as positive as published of learning also not previously explored this gap and overcome resistance, it is
descriptions of curricula suggest. One in the literature. Preclinical peers were important to explicitly acknowledge and
anecdotal account of how students seen as a nonthreatening source of appreciate what students bring to medical
perceive professionalism teaching states, constructive feedback, particularly in school. Lectures and small-group
“The current structure of professionalism settings with patient interaction; students discussions should analyze situations
education does more to harm students’ in the clinical years were viewed as unique to the medical setting and make it
virtue, confidence, and ethics than is reliable sources of professionalism clear that medical school professionalism
generally acknowledged” and that “we “pearls.” Students found it helpful to education is intended to build on,
students feel more victimized by the have faculty observe student–patient not replace, existing values and life
professionalism curricula than interactions and critique these in group experiences. In addition, presenting
enhanced.”30 Our qualitative methods settings so that students could learn from professionalism as a quality improvement
brought forth similar negative sentiments one another’s strengths and weaknesses. concern, as relevant to and necessary for
that students may usually express only Students were disappointed when faculty practicing physicians as for medical
privately. Both positive and negative did not correct peers who behaved students, may help students better
comments by our participants provide unprofessionally. Although literature contextualize discussions.39
insight into what motivates and what supports the teaching value of bedside
disengages preclinical students from rounds in the context of patient care,33,34 This study has several limitations. First, it
learning professionalism. our findings suggest that bedside teaching is a post hoc analysis of data gathered for
may promote professionalism during the curriculum evaluation. Second, students
Students had mixed reactions to formal preclinical years as well. Dedicated were not asked about each specific
lectures on professionalism. Some found faculty may be more likely to observe element of our professionalism
lectures inspirational and helpful for and interact closely with students curriculum, so reactions to a particular
elucidating observed professional during bedside teaching, increasing curricular component may not reflect the
behaviors. Comparable numbers opportunities for role modeling and for views of the entire cohort. In addition,
criticized lectures as “common sense,” faculty to observe and correct students’ students were specifically asked about
“obvious,” “nebulous,” or “ambiguous.” behaviors, than in clerkship settings in positive and negative role models
Our findings provide empiric evidence which faculty divide their attention and examples of professional and
for the perception that formal education between patient care and teaching. unprofessional behaviors, so they were
about professionalism may be seen as Whereas residents widely identify one- prompted to some extent to address role
insulting.31,32 If lectures remain a on-one patient interactions as important models. Third, students were responding
component of the formal curriculum in components of their professionalism to our unique professionalism
professionalism, educators should training,35,36 few students explicitly curriculum, so responses may not be
pinpoint and avoid those elements of identified solo interactions with generalizable to other schools. Finally,
lectures that evoke negative reactions. patients as formative to professional this qualitative study is based on a
Students’ specific suggestions to make development. This is to be expected for relatively small cohort of 56 students
lectures more meaningful included preclinical students with only six to seven across two years. Although numbers of
articulating an explicit and consistent compulsory patient contacts per year and responses in some domains and
definition of professionalism, focusing on no patient-care responsibility. However, categories within domains are provided,
tangible skills, making lectures evidence students who described experiences with these are not intended to be the bases for
based, and avoiding repetition. patients gave vivid descriptions revealing statistical or quantitative comparisons
awareness of their own “conscious but, rather, as indications of general
Students perceived role models, a part of incompetence,”37 and they recognized trends and directions. The qualitative
the informal curriculum, as the most their transition from student to nature of our study is designed to
important influence in their professional physician. Exploring these inner elucidate themes, and it may open the
development. This concurs with expert experiences may be an effective strategy door to future quantitative studies.
opinion.8 –10 However, the students for engaging students in reflection on
identified classroom faculty, in addition professional behaviors. By analyzing transcribed interviews, we
to clinical faculty, as positive and negative gained deeper, more nuanced insight into
role models, a finding that, to our A disconnect we found between our the success and failures of our curriculum
knowledge, has not been previously curriculum and students’ perceptions of than if we had relied on written course-
evaluation surveys or faculty impressions. Society of Internal Medicine; European patient-centered learning: Curriculum
In addition, we asked about a curriculum Federation of Internal Medicine. Medical change as an intervention for changing
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did or did not help them develop as National Board of Medical Examiners. University of Missouri–Kansas City School
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Correction
The April commentary by Harold Alan Pincus, MD, omitted some of the text because of a production error. The complete
commentary may be accessed at (http://links.lww.com/A1181)
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