Professionalism in Medical Student Education: Mapping the Clinical Curriculum

Nancy Payne, MD

 Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia

 

 

 

Introduction

Much emphasis has been placed on professional behavior over the course of the past several years, with national effort given to create a comprehensive definition of professionalism.   National organizations such as the AAMC, ABIM, ACGME, and NBME have composed the most widely used definitions.  Additionally, these organizations have constructed assessment tools to study student and physician professional behavior.  In this new era, medical universities are adopting the national definitions of professionalism and highlighting the importance of teaching and evaluating this core skill.

 

Like other skills in medical education, professionalism is learned through the formal, informal, and hidden curriculums.  Identifying informal and hidden curricular elements is difficult due to the implicit nature of these curriculums.  

 

 

Statement of the problem and project objectives

Although UVA identified professionalism as one of its twelve learning objectives for medical student education in 1996, the difficult task of isolating this curricular component has inhibited its full evaluation.  This project was designed in order to assist the Curriculum Committee in determining whether teaching of professionalism is adequately addressed in medical education at UVA. 

 

Project Objectives:

1.  To create a mapping system of the clinical curriculum;

2. To distinguish between teaching that occurs through the formal, informal and hidden curriculums.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1.   Professionalism in the formal curriculum

 

 

Description of the project/intervention

The UVA clinical curriculum extends across all four years of medical training.  Formal curricular elements were collected from the Curriculum Committee with regards to professionalism education within the clinical curriculum and are represented by an abbreviated outline (figure 1).  As a pilot study, this project has been implemented within the Department of Pediatrics  where informal curriculums were exposed through surveys of third year medical students at the completion of their pediatric clerkship (figure 2) and a focus group session with pediatric residents (figure 3).

 

Institutional policies, educational activities, resource allocation decisions, and health services research agendas were explored to determine the composition of the hidden curriculum with respect to professionalism.1 

 

 

Figure 2.

Medical student survey

given to students at the

completion of their pediatric

clerkship experience.

 

 

 

 Figure 2. Medical student survey given to students at the completion of their pediatric

clerkship experience.

 

 

 

Pediatric Clerkship Focus Group 2005 – Evaluating Professionalism in the Curriculum   What words would you use to define or describe professionalism? Has the medical school shaped your definition of professionalism?  If so, how? How/where have you seen faculty, residents, fellow medical students, nursing staff, other medical and ancillary staff: -         show respect -         act responsibly and with accountability -         demonstrate compassion, good communication What unprofessional behavior have you witnessed in faculty, residents, fellow medical students, nursing staff, other medical or ancillary staff? Describe a setting where you have seen someone: -         discuss patient care without respect for confidentiality -         speak with disrespect toward a patient, family member, or member of the healthcare team -         give suboptimal care to a patient -         make inappropriate comments on rounds What makes it difficult to uphold the attributes of professionalism?

 

Figure 3.   Focus group questionnaire,

abbreviated version for continued use with clerkship students.

 

 

Evaluation to date

Curriculum evaluation reveals that the skill of professionalism is taught throughout the four years of medical training explicitly in the formal clinical curriculum.  Implicit instruction in this skill occurs through the informal and hidden curriculums.     Examples of elements that bridge the informal and hidden curriculums with the formal medical school curriculum include:  the White Coat Ceremony, student professionalism performance feedback forms, the Humanism in Medicine Honor Society, and a Healer’s Art course.

 

Additional teaching within the informal curriculum is extrapolated from student responses to the clerkship survey.  Preliminary data from the pediatric clerkship students reflect that students observe professional behaviors while on their clerkship. Students most cite communication skills of pediatric residents as an exemplary model of professionalism. However, feedback from students implies that there are breaches of professionalism by peers, residents, and faculty during their clerkship experience, notably in the areas of confidentiality, disrespect of other professionals, and offering sub-optimal patient care (figure 4).

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 4.  Medical student observations of unprofessional behaviors witnessed during their clerkship. 

 

Pediatric residents’ answers to the focus group questionnaire support the students’ overwhelming positive remarks of professional behavior and suggest similar observations of unprofessional behavior.  According to residents, faculty have made family conference rooms presentable prior to family meetings and accepted responsibility when necessary for decisions which led to the poor outcome of a patient.  Senior residents assume responsibility for patient care while placing trust in the skills of interns, dress in a manner of respect, and call hospital staff by name.

 

Review of faculty development programs and policy manual updates overarching the health care system reveals hidden curricular elements emphasize professionalism through CME (continuing medical education) and the creation of new institutional policies.  Additionally, resources and evaluation activities have been dedicated to this skill through institutionally driven research grants. 

 

 

Key lessons learned so far and next steps

The formal, informal, and hidden curriculums at UVA address the skill of professionalism.  Within these curriculums, students learn behaviors of respect, responsibility and accountability, knowledge and skills, excellence in scholarship, honor and integrity, altruism, leadership, caring, compassion and communication.2 

 

The formal instruction given to the skill of professionalism is not necessarily where students learn the most about professional behavior.  As students witness resident and faculty role-modeling of professional and unprofessional behaviors and become attuned to the messages medical schools and hospitals give with respect to institutional policies, resource allocation decisions, and post-graduate educational activities, they learn from informal and hidden curriculums.1 

 

Even with curricular emphasis on professional behaviors, there is concern that curriculums may teach our students inadequately when the students’ clinical experience teaches them unprofessional behaviors.  The learning of professionalism can be described along a continuum, with positive and negative influences sharpening the development of this skill.  The attainment of professional standards should be sustained and the attrition that results from negative influences should be minimized.3

 

Next steps of this project include further collection of survey and focus group data within the pediatric clerkship, extension of data collection to other clerkships, and presentation of results to the Curriculum Committee for curriculum evaluation and discussion of planned interventions to address uncovered issues of concern.

 

Questions

 

1. Do student or faculty disciplinary programs impact professional behavior?
2. Does reflective practice influence professionalism?
3. Do the informal and hidden curriculums have more impact on what students learn regarding professionalism than lessons learned from a formal curriculum?

 

Literature cited

 

Hafferty, F.W. 1998.  Beyond Curriculum Reform:  Confronting Medicine’s Hidden Curriculum.  Academic Medicine 73(4): 403-407.

NBME Behaviors of Professionalism     http://ci.nbme.org/professionalsim/Behaviors.asp

Hilton, S. 2004.  Medical Professionalism: How Can We Encourage It in Our Students?  The Clinical Teacher 1(2):69-73.