ProfessionalismProfessionalismDavid TaylorDavid Taylor

Research questionResearch question

What do medical students and Doctors What do medical students and Doctors understand by the term understand by the term “professionalism”?“professionalism”? This matters because medical students This matters because medical students

are expected to develop as professionalsare expected to develop as professionals are tutor assessed are tutor assessed

Does their understanding change during Does their understanding change during their training?their training? Does Perry apply?Does Perry apply?

Dualism, relativism, comfortDualism, relativism, comfort Can we influence the rate of development?Can we influence the rate of development? Can we develop an inventory, or use an Can we develop an inventory, or use an

existing one?existing one? Would peer assessment work?Would peer assessment work?

What is knownWhat is known

Scribonius 47CE Scribonius 47CE The profession of medicine is The profession of medicine is

defined as a commitment to defined as a commitment to compassion or clemency in the compassion or clemency in the relief of suffering.relief of suffering.

Pellegrino 2002Pellegrino 2002 A profession is a public statement A profession is a public statement

of commitmentof commitment The doctor and the patient are in a The doctor and the patient are in a

covenantal relationshipcovenantal relationshipPellegrino, E.D., Professionalism, profession and the virtues of the good physician. Mt Sinai J Med, 2002. 69(6): p. 378-84 Philosophical discourse

RCP DefinitionRCP Definition

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

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

RCP DescriptionRCP Description

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

Doctors are committed Doctors are committed to:to:

IntegrityIntegrity CompassionCompassion AltruismAltruism Continuous improvementContinuous improvement ExcellenceExcellence Working in partnership with Working in partnership with

members of the wider healthcare members of the wider healthcare team.team.

Justice Potter StewartJustice Potter Stewart

I know it when I see it.I know it when I see it.

obscenityobscenity

Attitudes and values Attitudes and values Professional qualitiesProfessional qualities Professional Professional

behaviour behaviour Professional habitsProfessional habits Professional attitudes Professional attitudes Professional Professional

demeanourdemeanour Professional Professional

attributes/traits attributes/traits

Cohen 2001Cohen 2001

Personal Personal qualities/personality qualities/personality

Personal Personal characteristicscharacteristics

Psychosocial factorsPsychosocial factors Hard to assess Hard to assess Non-cognitive factorsNon-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?

Association for Surgical Education: Clinical Association for Surgical Education: Clinical Evaluation Protocols for Medical Students, Evaluation Protocols for Medical Students,

1985.1985.

QualityQuality % of schools% of schools

Relationship with patientsRelationship with patients 8282

Motivation Motivation 8181

Relationship with team membersRelationship with team members 7272

Relationship with teachersRelationship with teachers 5757

ResponsibilityResponsibility 4040

DependabilityDependability 3636

PunctualityPunctuality 2929

AppearanceAppearance 2525

Peer relationsPeer relations 2020

Integrity/honestyIntegrity/honesty 1616

attitudeattitude 14.614.6

Ethical conductEthical conduct 6.86.8

Ability to work independentlyAbility to work independently 66

Willingness to seek helpWillingness to seek help 5.25.2

Work habitsWork habits 3.53.5

Larry Gruppen,(2005) Larry Gruppen,(2005) MichiganMichigan

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

Van de Camp(2004)Van de Camp(2004)

Medline search using Cohen’s domainsMedline search using Cohen’s domains Plus hand searching the referencesPlus hand searching the references Yielded 173 articlesYielded 173 articles Applying inclusion/exclusion criteria Applying inclusion/exclusion criteria

resulted in 57 articlesresulted in 57 articles From which 90 items were culledFrom which 90 items were culled Sorted into domains by modified Sorted into domains by modified

Delphi techniqueDelphi 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

3 domains3 domains

Interpersonal professionalismInterpersonal professionalism Meeting demands for adequate contact Meeting demands for adequate contact

with patients and other health with patients and other health professionalsprofessionals

Altruism, respect, integrity, service, honour,…Altruism, respect, integrity, service, honour,…

Public professionalismPublic professionalism Meeting society’s demandsMeeting society’s demands

Accountability, submission to an ethical Accountability, submission to an ethical code/moral commitment,…code/moral commitment,…

Intrapersonal professionalismIntrapersonal professionalism Meeting the demands of the professional Meeting the demands of the professional

bodybody Lifelong learning, maturity, morality,…Lifelong learning, maturity, morality,…

The first stepThe first step Design a Q-sort based on the 90 itemsDesign a Q-sort based on the 90 items Advantages of Q-sortAdvantages of Q-sort

Fun and easy to performFun and easy to perform Computerised analysis packageComputerised analysis package Gives useable and meaningful numbersGives useable and meaningful numbers Data richData rich

DisadvantageDisadvantage Small sample sizeSmall sample size

But trade that off by using it to develop a But trade that off by using it to develop a questionnaire-type instrumentquestionnaire-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).

Why Q-sorts ?Why Q-sorts ?

It forces people to make choicesIt forces people to make choices

And because the data is normally And because the data is normally distributed, comparison between distributed, comparison between subjects is easiersubjects is easier

And factor analysis is possibleAnd factor analysis is possible

Q-sort ordering (80 Q-sort ordering (80 items)items)

43210 5 6 7 8Pile

4 6 10 12 16 12 10 6 4

Agree Neutral Disagree

Cards

Data processingData processing

Sayle and Taylor ASME Sayle and Taylor ASME 20062006

The five most favoured items The five most favoured items describing professionalism, in describing professionalism, in order, were:order, were: Good clinical Good clinical judgementjudgement, , competence, competence, responsibility, responsibility, protect confidential information, protect confidential information, honestyhonesty

Next stagesNext stages

We need a bigger “n” to have confidence We need a bigger “n” to have confidence over the factor analysisover the factor analysis Chronbach’s alpha is good, but then the number Chronbach’s alpha is good, but then the number

of items is high!of items is high! We need to see if 3We need to see if 3rdrd year students differ year students differ

from 1from 1stst or 5 or 5thth years years We need to see if students differ from We need to see if students differ from

DoctorsDoctors It would be It would be reallyreally interesting to see if Perry’s interesting to see if Perry’s

framework applies framework applies and when they move from A to B – is C ever and when they move from A to B – is C ever

reached?!reached?! Then we need to design an instrument using Then we need to design an instrument using

the critical domains.the critical domains.

Perry Type APerry Type A

1.Basic Duality 1.Basic Duality • Reality with no uncertainty or diversity, belief Reality with no uncertainty or diversity, belief

in absolute answers and authorities, in absolute answers and authorities, obedience instead of responsibility.obedience instead of responsibility.

2.Multiplicity pre-legitimate 2.Multiplicity pre-legitimate • Perception of diversity, but classified as Perception of diversity, but classified as

unwarranted confusion.unwarranted confusion.

3. Multiplicity sub-ordinate 3. Multiplicity sub-ordinate • Diversity and uncertainty accepted, but Diversity and uncertainty accepted, but

classified as temporary in a search for classified as temporary in a search for absolute answers.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.

Perry Type BPerry Type B

4. Multiplicity correlate or First attempt to 4. Multiplicity correlate or First attempt to accommodate diversity and uncertaintyaccommodate diversity and uncertainty relativism subordinate with the expectation to do relativism subordinate with the expectation to do

the right thing either by accepting no answers as the right thing either by accepting no answers as truth-bearing or by subordinating to authority.truth-bearing or by subordinating to authority.

5.Relativism correlate,5.Relativism correlate, Revolution through the inability to assimilate Revolution through the inability to assimilate

uncertainty competing, diffuse and the existence uncertainty competing, diffuse and the existence of absolute answers, everything becomes of absolute answers, everything becomes relativistic.relativistic.

6. Commitment foreseen 6. Commitment foreseen Awareness of the need of orientation in a Awareness of the need of orientation in a

relativistic world, experimentation with different relativistic world, experimentation with different methodsmethods

Perry Type CPerry Type C

7. Initial commitment 7. Initial commitment Initial commitment in one area.Initial commitment in one area.

8. Orientation in implications of commitment 8. Orientation in implications of commitment Experiences with commitment and responsibility, Experiences with commitment and responsibility,

time of personal choices of how to fulfil perceived time of personal choices of how to fulfil perceived responsibility.responsibility.

9. Developing commitment 9. Developing commitment Affirmation of identity among multiple Affirmation of identity among multiple

responsibilities, commitment seen as an ongoing responsibilities, commitment seen as an ongoing activity.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.