Vikram Jha

Teaching and assessment of student attitudes towards professionalism in medicine: 

Teaching and assessment of student attitudes towards professionalism in medicine Vikram Jha Senior Lecturer in Medical Education University of Leeds Acknowledgement: www.cartoonstock.com

Profession: 

Profession The occupation which one professes to be skilled in or to follow- A vocation in which professional body of knowledge is used in its application to the affairs of others or in the practice of an art founded upon it In a wider sense any calling or occupation by which a person habitually earns his/her living

So is there a difference?: 

So is there a difference? Some professions require intellectual training and acquisition of specialised knowledge Work is pursued primarily for others Success is measured by more than financial return Brandeis LD. Business-A profession. Boston, MA: Small, Maynard, 1914

History of Medical Professionalism: 

History of Medical Professionalism Early literature (1910-1940) favourable-faith in virtue, morality, service commitment 1960-1970-less favourable-scepticism regarding altruism, self-serving, misuse of power Post 1980-more favourable-more critical of state/services Recent high profile cases-Shipman, Bristol

Sociology and medicine: 

Sociology and medicine Dominance of medicine is decreasing Proletarianization has decreased status and economy-we need to sell our services Deprofessionalisation has occurred (moral) Corporatisation and bureaucratization are trends

Ethics and medicine: 

Ethics and medicine Concept of healer Trust Patient-physician relationship Fiduciary relationship-for the good Beneficence

Dilemma: 

Dilemma Dual role-healer and professional Healer (constant)-Hippocratic oath Professional (changing)-Business Change in societal expectations

Business versus Professional values: 

Business versus Professional values “The practice of medicine is not a business and can never be one…Our fellow creatures cannot be dealt with as man deals in corn or coal.” (William Osler 1932) Osler W. On the educational value of the medical society. In: Aequanimitas, with other addresses to medical students, nurses and practitioners of medicine. 3rd Ed. Philadelphia, PA, 1932: 329-45

Current emphasis on medical professionalism: 

Current emphasis on medical professionalism More complaints against physicians relate to unprofessional conduct than lack of knowledge or poor technical skills (Ginsburg et al 2000) Ginsburg S et al Context, conflict and resolution: A new conceptual framework for evaluating professionalism. Academic Medicine, 75 (10) Suppl 2000

Slide16: 

Problematic behaviour in school associated with disciplinary action (Papadakis et al 2004) Papadakis MA, Hodgson CS, Teherani et al. Unprofessional behaviour in medical school is associated with subsequent disciplinary action by a State Medical Board. Academic Medicine 2004; 79 (3): 244-249

Slide17: 

Difficulty with defining and measuring professionalism is well recognised (Baldwin and Bunch 2000) Baldwin DC Jr, Bunch WH. Moral reasoning, professionalism, and the teaching of ethics to orthopaedic surgeons. Clinical Orthopaedics and Related Research 2000; 378: 97-103.

What is medical professionalism?: 

What is medical professionalism? Medical Professionalism in the New Millennium: A Physician Charter (ABIMF, ACP-ASIMF, EFIM 2002) Principles: Primacy of patient welfare Patient autonomy Social justice ABIM Foundation, ACP-ASIM Foundation and European Federation of Internal Medicine. Medical Professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002; 136: 243-6

Duties of a Doctor (GMC2001): 

Duties of a Doctor (GMC2001) Attributes: Polite, honest, trustworthy, unprejudiced, respectful Skills: Communication, technical Behaviour/attitudes Confidentiality, error reporting, not abusing position as doctor

Normative definition of professionalism (Swick 2000): 

Normative definition of professionalism (Swick 2000) Subordination of own interests to interests of others Adherence to high ethical and moral standards Respond to social needs Core humanistic values Accountability Excellence Commitment to scholarship Reflection Swick HM. Towards a normative definition of Medical Professionalism. Academic Medicine 2000; 75 (6): 612-616

Problems: 

Problems No guidance from GMC Formalisation of teaching and assessment enhances perceived importance Nebulous terms cannot be operationalised Context, conflict and resolution (Ginsburg et al 2000) Ginsburg S et al Context, conflict and resolution: A new conceptual framework for evaluating professionalism. Academic Medicine, 75 (10) Suppl 2000

Attitudes or behaviour: 

Attitudes or behaviour Attitude-disposition to respond favourably or not to something Inaccessible to direct observation Inferred from measurable responses (Ajzen 1996)

Resonses to attitudes: 

Resonses to attitudes Cognitive-beliefs Affective-feelings Conative-behaviour

Attitudes and behaviour: 

Attitudes and behaviour Behaviour influenced by attitudes Aggregation theory (Fishbein and Ajzen 1974) Global attitudes better at predciting aggregates of behaviour or multiple behaviour over wide range of contexts Theory of planned behaviour

Views on professionalism : 

Views on professionalism 7 main themes identified Theme includes number of aspects of professionalism grouped together Idea of more global and broader concepts of professionalism than individual attributes and behaviours Jha V, Bekker HL, Duffy SRG, Roberts TE. Perceptions of professionalism in medicine: a qualitative study. Medical Education 2006; 40: 1027-1036

Pause to think: 

Pause to think Would you send your daughter to see a gynaecologist who is known to download pornography?

Views on professionalism: 

Views on professionalism Easy to state attribute/behaviour but difficult to conceptualise Largely contextual Sometimes grey Hierarchy of professionalism

Compliance to value system: 

Compliance to value system “We were talking about attributes for a Dean and there was discussion about whether you wanted somebody who could lie well and blithely or somebody who inevitably had to blurt out the truth”.

Patient access: 

Patient access

Physician-patient relationship: 

Physician-patient relationship

Demeanour: 

Demeanour “The gynaecologist came in wearing his hunting gear, slapping the side of his breeches with his riding crop and extremely loud and arrogant”.

Management: 

Management Personal and collective Change from healer to professional

Personal awareness: 

Personal awareness “I think people are entitled to have prejudices- I think it would be hard to find a single person in the world who doesn't have some prejudice of one sort or another”.

Motivation: 

Motivation “Altruism is difficult, in the American literature they emphasise altruism and I'm not sure whether this is American hype”.

What is professionalism?: 

What is professionalism? Core aspects-compliance to value system Others not as generic Proto-professionalism (Hilton)- Phronesis-practical wisdom-when to break rules

Professionalism endangered: 

Professionalism endangered Expert professionalism versus social-trustee professionalism (Swick 2000) Professional autonomy versus external review Medical culture versus business/political culture Swick HM. Towards a normative definition of Medical Professionalism. Academic Medicine 2000; 75 (6): 612-616

Teaching professionalism: 

Teaching professionalism Teaching of professional values occurs most often in an informal setting, such as whilst having dinner or working together on call rather than in more formal settings such as lectures or attending rounds (Stern 1998) Stern DT. In search of the informal curriculum: when and where professional values are taught. Academic Medicine 1998; 73 (10 suppl): S28-30.

Teaching of professionalism: 

Teaching of professionalism Identify aspects in curriculum devoted to professionalism Reinforce this in postgraduate and CME Concept that to be a professional is not a right but a privilege Separate but linked concepts of physician as healer and as professional (for delivery of service)

Teaching of professionalism: 

Teaching of professionalism Define professionalism and components Professionalism is an ideal to be pursued with inherent moral value Professionalism essential to maintain trust of patients Knowledge of codes of ethics governing conduct of both healer and professional

Teaching of professionalism: 

Teaching of professionalism Nature and limitations of autonomy-individual and collective Relevant material drawn from sociology, philosophy, economics related to professionalism Link between professional status and obligations to society that must be fulfilled to maintain public trust

Methods of teaching professionalism: 

Methods of teaching professionalism Courses-moral reasoning, physician-patient communication, medical ethics, law Innovative teaching methods-experiential, reflective, self-directed learning. PBL Student and teacher support and guidance

Assessment of professionalism: 

Assessment of professionalism Lynch (2004) systematic review 191 articles with 88 assessment descriptions in 12 categories: Ethics:affective/cognitive/behavioural/environmental Personal characteristics-affective Comprehensive professionalism-Cognitive/behavioural/environmental Diversity-cognitive/behavioural/environmental Lynch DC et al Assessing professionalism: a review of the literature. Medical Teacher, 26 (4), 2004, 366-373

Systematic review of assessmentof attitudes towardsprofessionalismJha V, Bekker HL, Duffy SRG, Roberts TE. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine-in press: 

Systematic review of assessment of attitudes towards professionalism Jha V, Bekker HL, Duffy SRG, Roberts TE. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine-in press 97 articles in all 14-professionalism in general 31-ethical issues 12-academic integrity 7-personal values 22-acceptable behaviour (pt-phy relations) 9-cultural issues 1-attire

Types of measures: 

Types of measures Attitude scales-44 Response to vignettes-23 Questionnaires-13 Combinations-9 Others-interviews,essays-8

Problems with measures: 

Problems with measures Few measured attitudes towards professionalism in general Details of derivation of items Only 15 measured attitudes longitudinally 38 reported both reliability and validity No theory underpinning measures

Interventions to promote professionalism: 

Interventions to promote professionalism 17 articles Courses-Ethics course, cultural issues Individual teaching sessions-appropriateness of sexual contact Curriculum-socio-cultural medicine program 3 showed no effect No long term effect

Theory of planned behaviour (Ajzen 1991): 

Theory of planned behaviour (Ajzen 1991)

Questionnaire: 

Questionnaire TPB framework Items from qualitative study on views on professionalism 27 professional behaviours on 4 themes 243 items 400 students Jha V, Bekker HL, Roberts TE. A measure of medical students’ attitudes towards professionalism. Unpublished data

Compliance to values: 

Compliance to values Being economical with truth sometimes when talking to patients Reporting colleagues for lacking clinical skills Talk about patients without using their names Report friend for cheating Using tissue for research without consent Disclose diagnosis to relative Think less of colleague for drinking on call Have intimate relations with juniors

Patient-physician relationship: 

Patient-physician relationship Be available to patients all hours of day Choose treatment options to offer Engage with broader community Put patient needs before own Accept patient choice even when disagree Make comments about appearance of anesthetised patient

Management: 

Management Contradict colleagues in front of patients Give all team members same respect Act superior in front of patients

Personal awareness: 

Personal awareness Admit limitation of knowledge Change what they say depending on patient's job Dress smartly Ask for help from colleagues Audit performance Tell sexist jokes

Central components of TPB: 

Central components of TPB Behaviour-not included Attitude-direct Behavioural intentions Behavioural beliefs-beliefs and outcomes Subjective norms-beliefs and motivation to comply Perceived behavioural control-beliefs and perceived power Past behaviour

Psychometric properties: 

Psychometric properties Good correlation between TPB variables Attitudes and subjective norms strongest predictors Strong link with past behaviour Stability of attitudes over 5 years Higher attitude scores for females in management

Development of measure of attitudes towards professionlism: 

Development of measure of attitudes towards professionlism Professionalism is difficult to define let alone teach or assess Core aspects may be generic

Future: 

Future Put theory into practice Include subjective norms and perceived behavioural control Interventions should be based on sound theoretical principles