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Teaching Professionalism in Undergraduate Medical Education
Herbert M. Swick, MD;
Philip Szenas, MA;
Deborah Danoff, MD;
Michael E. Whitcomb, MD
JAMA. 1999;282:830-832.
ABSTRACT
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Context There is a growing consensus among medical educators that to promote the professional development of medical students, schools of medicine should provide explicit learning experiences in professionalism.
Objective To determine whether and how schools of medicine were teaching professionalism in the 1998-1999 academic year.
Design, Setting, and Participants A 2-stage survey was sent to 125 US medical schools in the fall of 1998. A total of 116 (92.3%) responded to the first stage of the survey. The second survey led to a qualitative analysis of curriculum materials submitted by 41 schools.
Main Outcome Measures Presence or absence of learning experiences (didactic or experiential) in undergraduate medical curriculum explicitly intended to promote professionalism in medical students, with curriculum evaluation based on 4 attributes commonly recognized as essential to professionalism: subordination of one's self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of evincible core humanistic values.
Results Of the 116 responding medical schools, 104 (89.7%) reported that they offer some formal instruction related to professionalism. Fewer schools have explicit methods for assessing professional behaviors (n=64 [55.2%]) or conduct targeted faculty development programs (n=39 [33.6%]). Schools use diverse strategies to promote professionalism, ranging from an isolated white-coat ceremony or other orientation experience (n=71 [78.9%]) to an integrated sequence of courses over multiple years of the curriculum (n=25 [27.8%]). Of the 41 schools that provided curriculum materials, 27 (65.9%) addressed subordinating self-interests; 31 (75.6%), adhering to high ethical and moral standards; 17 (41.5%), responding to societal needs; and 22 (53.7%), evincing core humanistic values.
Conclusions Our results suggest that the teaching of professionalism in undergraduate medical education varies widely. Although most medical schools in the United States now address this important topic in some manner, the strategies used to teach professionalism may not always be adequate.
INTRODUCTION
There is a growing awareness, both within and outside the medical profession, that the corporate transformation of the US health care system threatens to undermine the professionalism of physicians.1 The rise of managed care and consumerism in medicine have led many to worry about changes both in physicians' attitudes about their roles and responsibilities and in the behaviors they demonstrate in the daily practice of medicine. Medical educators have become concerned about an erosion of medical professionalism because of the impact that the attitudes and behaviors of practicing physicians, particularly clinical faculty, have on the professional development of medical students and resident physicians.
Reflecting these concerns, the Section on Medical Schools of the American Medical Association devoted its May 1998 meeting to an exploration of certain aspects of professionalism, and in July 1998, the Association of American Medical Colleges sponsored a colloquium of medical educators, ethicists, and experts from law and philosophy who had written about professionalism. These meetings contributed to the development of a consensus among medical educators that medical schools should offer both didactic and experiential learning experiences designed to promote the development of professionalism among medical students and resident physicians. In response to this consensus, we conducted a survey of US medical schools to determine whether they were teaching professionalism, and if so, how. This article reports the results of that survey.
METHODS
Data Collection
A 2-stage survey of US medical schools was conducted in the fall of 1998. In the first stage, a 1-page survey instrument was sent to the associate dean responsible for the medical student education program at each school. The survey instrument was intended to gain general information about a school's activities related to the teaching of professionalism (questions 1-3 and 8, Table 1). Even though professionalism is a complex concept encompassing a number of attitudes, values, and behaviors, the survey instrument focused attention on only 4 attributes: (1) subordinating one's self-interest to the interest of patients; (2) adhering to high ethical and moral standards; (3) responding to societal needs; and (4) evincing core humanistic values (eg, empathy, integrity, altruism, trustworthiness). The authors selected these 4 attributes because they have often been recognized as essential elements of professionalism2-5 and because they were thought to be the attributes most likely to be addressed formally by schools.
In the second stage, a more detailed survey instrument was sent to those schools that reported on the first instrument that they did offer some formal instruction in professionalism. The second survey instrument was designed to determine when and in what format professionalism was taught, as well as the specific goals and objectives of such curricular offerings (questions 4-7, Table 1). This instrument was directed toward a specific contact person—most often a course or program director—identified in the first survey. These individuals also were asked to submit copies of curriculum materials used in courses related to professionalism.
Data Analysis
Simple descriptive statistics (frequencies and percentages) were computed for each survey question. In addition, curriculum materials, ranging from brief outlines to multivolume syllabi, were reviewed by one of the authors (H.M.S.) to determine when and how a school conveyed attributes of professionalism. The reviewer used both a key word descriptive approach to ascertain if the materials used explicit language related to 1 of the core attributes and a more subjective approach to determine whether the presentation of certain topics addressed 1 of the core attributes. An example of the key word approach would be a discussion of specific ethical behaviors in a course on biomedical ethics. An example of the subjective approach would be the reviewer's determination of whether a presentation on access to care for the uninsured reflected a physician's social responsibility, based on the reviewer's judgment of stated course objectives or other materials.
RESULTS
Response Rates
Of the 125 US medical schools, 116 (92.3%) responded to the first stage of the survey. The second survey instrument was sent to the 104 schools that indicated that they did offer formal instruction on professionalism. Of those, 90 (86.5%) schools responded; 41 (75.9%) of the 54 schools that indicated they had a course syllabus or similar materials submitted those materials for review.
Survey Results
The results of the survey are summarized in Table 1. A total of 104 (89.7%) of the responding US medical schools reported that they had some formal instruction related to professionalism. Slightly more than half of the responding schools (64 [55.2%]) reported having an explicit rigorous process to assess the students' professional behaviors, while 39 (33.6%) had targeted faculty development programs.
The majority of schools (71 [78.9%]) that address professionalism do so during orientation, often in a "white-coat ceremony" designed to symbolize the matriculating students' induction into the medical profession6; a smaller majority of schools (54 [60%]) incorporate professionalism as a component of multiple courses (question 4, Table 1). Fewer than a third of the schools (26 [28.9%]) reported that they teach professionalism in a single course or as an integrated sequence of courses (25 [27.8%]). Of the schools reporting that they taught professionalism, 56 (68.3%) had written goals or objectives, 52 (63.4%) provided course outlines for students or faculty, and 54 (65.9%) used a syllabus or other written materials.
Schools appeared to recognize some inadequacies in their approach to professionalism. The majority of the schools that responded to the first survey instrument indicated that their efforts to teach professionalism would benefit from examples of evaluation instruments (84.5%), faculty development materials (81.9%), and formal teaching materials or model programs (76.7%).
Curriculum Materials Review
The analysis of the curriculum materials provided by the 41 schools revealed significant variation in the number of schools covering the 4 selected attributes of professionalism in 1 or more of their courses. While about three quarters of the schools covered the attribute "adhere to high ethical and moral standards," fewer than half addressed the attribute "respond to societal needs and reflect a social contract with the communities served" (Table 2). The data reported in Table 2 are derived from both the key word and the more subjective approaches.
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Table 2. Attributes of Professionalism Taught in 41 Schools
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Most of the explicit teaching of professionalism occurred during the first 2 years, whether in a single course or in multiple courses. Only 8 of the 41 schools submitted materials related to explicit learning experiences conducted in the last 2 years of the curriculum. The most common approach, used by 20 of the 41 schools, was to incorporate various concepts of professionalism into 1 or more courses that focused on a variety of topics in which professionalism is addressed indirectly.
COMMENT
For many years, the acquisition of professional values and behaviors occurred largely through an informal process of socialization that extended from medical school through residency and fellowship training. As issues of medical practice have become more complex and as students enter the study of medicine from increasingly diverse social, cultural, and socioeconomic backgrounds, schools of medicine have recognized that such an informal process no longer suffices. While role modeling and experiential learning remain critically important, many schools perceive the need also to offer explicit learning activities that will inculcate in students and residents the knowledge, values, attitudes, and behaviors that characterize medical professionalism.
The survey results presented in this article reflect the status in 1998 of the explicit teaching of professionalism in US medical schools. To the best of our knowledge, this study is the first designed to gain insight into whether and how medical schools are teaching professionalism. The survey data must be interpreted with caution because the responses to the survey questions are undoubtedly affected by the general lack of a common understanding of the meaning of medical professionalism. Nonetheless, a few general observations deserve emphasis.
Both the surveys and the review of curriculum materials indicate that the great majority of schools recognize the need to address professionalism as a critical element of the education of their students. However, it is noteworthy that 10% of the respondents to the initial survey reported that their school did not have any recognized curriculum content that addressed professionalism, whether explicitly or implicitly. Also of note, only one half of the schools that reported having curriculum content related to professionalism indicated having formal methods for assessing the professional behaviors of students. Finally, the review of the course materials submitted by 41 (76%) of the 54 schools that indicated they had such materials suggests that schools do not cover, in an explicit manner, several of the essential attributes of medical professionalism.
The results of this study suggest that the teaching of professionalism in US medical schools needs to be enhanced. Schools would benefit from examples or models of how professionalism might be defined, taught, and assessed. While most medical schools seem to recognize that explicit learning experiences are necessary to promote professional values and behaviors in medical students, the strategies used to achieve that goal appear inadequate. Although some schools are quite organized in their approach to teaching professionalism, many are not. Few have an approach that attempts specifically to foster the development of professional values and behaviors. Many schools do not provide instruction on the characteristics of a profession or on the history and meaning of medical professionalism in the context of the current health care system. In the past few years, several observers have argued that if physicians are to meet their responsibilities to their patients, to the profession, and to society, formal teaching of professionalism should be embedded in the medical school curriculum.7-10 The results of this study underscore the importance of responding to their arguments.
AUTHOR INFORMATION
Corresponding Author: Michael E. Whitcomb, MD, Division of Medical Education, Association of American Medical Colleges, 2450 N St NW, Washington, DC 20037.
Author Affiliations: Association of American Medical Colleges, Washington, DC. Dr Swick is with the Department of Neurology, University of Kansas, Kansas City. He is currently a scholar in residence with the Association of American Medical Colleges.
REFERENCES
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1. Sullivan WM. What is left of professionalism after managed care? Hastings Center Rep. 1999;29:7-13.
2. American Board of Internal Medicine. Project Professionalism. Philadelphia, Pa: American Board of Internal Medicine; 1995.
3. Brint S. In an Age of Experts: The Changing Role of Professionals in Politics and Public Life. Princeton, NJ: Princeton University Press; 1994.
4. Sullivan WM. Work and Integrity: The Crisis and Promise of Professionalism in America. New York, NY: Harper Collins; 1995.
5. Swick HM. Academic medicine must deal with the clash of business and professional values. Acad Med. 1998;73:751-755.
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6. Wear D. On white coats and professional development: the formal and hidden curricula. Ann Intern Med. 1998;129:734-737.
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7. Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941-952.
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8. Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med. 1994;120:609-614.
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9. Hensel WA, Dickey NW. Teaching professionalism: passing the torch. Acad Med. 1998;73:865-870.
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10. Relman AS. Education to defend professional values in the new corporate age. Acad Med. 1998;73:1229-1233.
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