Professionalism

1
Professionalism

• David Taylor

2
Research question

• What do medical students and Doctors understand
  by the term professionalism?
• This matters because medical students
• are expected to develop as professionals
• are tutor assessed
• Does their understanding change during their
  training?
• Does Perry apply?
• Dualism, relativism, comfort
• Can we influence the rate of development?
• Can we develop an inventory, or use an existing
  one?
• Would peer assessment work?

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What is known

• Scribonius 47CE
• The profession of medicine is defined as a
  commitment to compassion or clemency in the
  relief of suffering.
• Pellegrino 2002
• A profession is a public statement of commitment
• The doctor and the patient are in a covenantal
  relationship

Pellegrino, E.D., Professionalism, profession and
the virtues of the good physician. Mt Sinai J
Med, 2002. 69(6) p. 378-84 Philosophical
discourse
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RCP Definition

• Medical professionalism signifies a set of
  values, behaviours, and relationships that
  underpins the trust the public has in doctors

Royal College of Physicians, Doctors in
SocietyMedical professionalism in a changing
world. 2005, RCP London. Interviews and expert
group analysis
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RCP Description

• Medicine is a vocation in which a doctors
  knowledge, clinical skills, and judgement are put
  in the service of protecting and restoring human
  well-being. This purpose is realised through a
  partnership between patient and doctor, one based
  on mutual respect, individual responsibility, and
  appropriate accountability.

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Doctors are committed to

• Integrity
• Compassion
• Altruism
• Continuous improvement
• Excellence
• Working in partnership with members of the wider
  healthcare team.

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Justice Potter Stewart

• I know it when I see it.
• obscenity

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Cohen 2001

• Attitudes and values
• Professional qualities
• Professional behaviour
• Professional habits
• Professional attitudes
• Professional demeanour
• Professional attributes/traits

• Personal qualities/personality
• Personal characteristics
• Psychosocial factors
• Hard to assess
• Non-cognitive factors

Cohen, R., Assessing professional behaviour and
medical error. Med Teach, 2001. 23(2) p.
145-151. Cohen calls for direct observation of
clinical performance but what criteria?
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Association for Surgical Education Clinical
Evaluation Protocols for Medical Students, 1985.
Quality of schools
Relationship with patients 82
Motivation 81
Relationship with team members 72
Relationship with teachers 57
Responsibility 40
Dependability 36
Punctuality 29
Appearance 25
Peer relations 20
Integrity/honesty 16
attitude 14.6
Ethical conduct 6.8
Ability to work independently 6
Willingness to seek help 5.2
Work habits 3.5
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Larry Gruppen,(2005) Michigan
Gauger, P.G., et al., Initial use of a novel
instrument to measure professionalism in surgical
residents. Am J Surg, 2005. 189(4) p. 479-87.
expert group analysis
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Van de Camp(2004)

• Medline search using Cohens domains
• Plus hand searching the references
• Yielded 173 articles
• Applying inclusion/exclusion criteria resulted in
  57 articles
• From which 90 items were culled
• Sorted into domains by modified Delphi technique

Van De Camp, K., et al., How to conceptualize
professionalism a qualitative study. Med Teach,
2004. 26(8) p. 696-702. Expert group analysis
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3 domains

• Interpersonal professionalism
• Meeting demands for adequate contact with
  patients and other health professionals
• Altruism, respect, integrity, service, honour,
• Public professionalism
• Meeting societys demands
• Accountability, submission to an ethical
  code/moral commitment,
• Intrapersonal professionalism
• Meeting the demands of the professional body
• Lifelong learning, maturity, morality,

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The first step

• Design a Q-sort based on the 90 items
• Advantages of Q-sort
• Fun and easy to perform
• Computerised analysis package
• Gives useable and meaningful numbers
• Data rich
• Disadvantage
• Small sample size
• But trade that off by using it to develop a
  questionnaire-type instrument

Kerlinger, F.N., Foundations of Behavioural
Research. 1986, New York Holt, Rinehart and
Winston Block, Jack (1961/1978) The Q-sort
method in personality assessment and psychiatric
research. Springfield, IL Charles C. Thomas.
(reprinted in 1978 by Consulting Psychologists
Press, Palo Alto, CA).
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Why Q-sorts ?

• It forces people to make choices
• And because the data is normally distributed,
  comparison between subjects is easier
• And factor analysis is possible

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Q-sort ordering (80 items)
4
3
2
1
0
5
6
7
8
Pile
4
6
10
12
16
12
10
6
4
Cards
Agree
Disagree
Neutral
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Data processing
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Sayle and Taylor ASME 2006

• The five most favoured items describing
  professionalism, in order, were
• Good clinical judgement,
• competence,
• responsibility,
• protect confidential information,
• honesty

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Next stages

• We need a bigger n to have confidence over the
  factor analysis
• Chronbachs alpha is good, but then the number of
  items is high!
• We need to see if 3rd year students differ from
  1st or 5th years
• We need to see if students differ from Doctors
• It would be really interesting to see if Perrys
  framework applies
• and when they move from A to B is C ever
  reached?!
• Then we need to design an instrument using the
  critical domains.

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Perry Type A

• 1.Basic Duality
• Reality with no uncertainty or diversity, belief
  in absolute answers and authorities, obedience
  instead of responsibility.
• 2.Multiplicity pre-legitimate
• Perception of diversity, but classified as
  unwarranted confusion.
• 3. Multiplicity sub-ordinate
• Diversity and uncertainty accepted, but
  classified as temporary in a search for absolute
  answers.

Clarkeburn, H.M., et al., Measuring Ethical
Development in Life Sciences Students a study
using Perry's developmental model. Studies in
Higher Education, 2003. 28(4) p. 443-456.
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Perry Type B

• 4. Multiplicity correlate or First attempt to
  accommodate diversity and uncertainty
• relativism subordinate with the expectation to do
  the right thing either by accepting no answers as
  truth-bearing or by subordinating to authority.
• 5.Relativism correlate,
• Revolution through the inability to assimilate
  uncertainty competing, diffuse and the existence
  of absolute answers, everything becomes
  relativistic.
• 6. Commitment foreseen
• Awareness of the need of orientation in a
  relativistic world, experimentation with
  different methods

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Perry Type C

• 7. Initial commitment
• Initial commitment in one area.
• 8. Orientation in implications of commitment
• Experiences with commitment and responsibility,
  time of personal choices of how to fulfil
  perceived responsibility.
• 9. Developing commitment
• Affirmation of identity among multiple
  responsibilities, commitment seen as an ongoing
  activity.

There is an excellent inventory Yang, F.-Y.,
Student views concerning evidence and the expert
in reasoning a socio-scientific issue and
personal epistemology. Educational Studies, 2005.
31(1) p. 65-84.