A Practical Framework for Workplace-Based Teaching of Professionalism to Medical Students

Dear Editor,

The nature of the medical profession has profoundly changed in the recent decades. The private sector had an explosive expansion and the patient-doctor relationship shifted dangerously towards a brand-customer type of interaction. Inevitably, the era of “commercialized medicine” (1) led to disbelief amongst the public regarding the traditional values of the profession. As a response to address these concerns, medical curricula across the globe went through a series of structural reforms which have seen professionalism become a fully-fledged core competency, now expected even at an undergraduate level. At present, however, a unifying model for the teaching of professionalism has yet to be agreed (2). Formal lectures have been received with mixed perceptions by medical students; for most of them, the mere sermonising of standards of professional conduct has produced the feeling that professionalism simply boils down to common sense (3). On the other hand, when professionalism is taught with the use of an authentic real-life context to demonstrate and explain its cognitive base, teaching seems to be more impactful (2). Role modelling gives students the possibility to observe behaviours in action and it encourages them to reflect on the professional challenges witnessed during day-to-day working life.

The question of how to effectively mentor students in the ward environment, however, remains. We are junior residents in teaching hospitals and we realized that we represent the main source of behaviours that medical students tend to internalise and replicate. How can we showcase professionalism? Is it doing our normal job in a “professional” manner while being watched by students enough? probably not. The teaching of professionalism cannot be left by chance alone. A structured approach is vital in order to ensure that medical students internalise this complex and multi-dimensional construct. We are therefore proposing a practical 3-step framework which is based on the situated learning theory, nowadays recognized as the best theoretical basis for the development of a structured teaching programme of professionalism (2).

It is fundamental that the teacher is familiar with the principles of professionalism. Equally important is being aware of representing a role model of professionalism for medical students; consciously recognising that what we are modelling can have a positive or negative impact on students is crucial to improve our teaching strategy (4). Small group discussions with medical students can initially be used as an effective way to reach a common understanding of what professionalism is (5). The discussion should have a natural flow and the teacher might intervene to ensure that all aspects of professionalism, such as patient-centred practice, integrity, accountability, and empathy, are touched upon. As students will already know the cognitive base of professionalism, as part of the formal lectures built into their curriculum, simulating a lecture in the ward should be avoided. Instead, these small-group discussions can be used to allow students to freely give their definition of professionalism, to explore its nuances and grey areas, and to articulate their understanding in relation to past positive and negative experiences. Discussing professionalism through discourses and story-telling, rather than imposing “guidelines of professionalism”, helps student to gain a more sophisticated sense of what professionalism is (6). That said, the mentor should use his professional judgment and communication skills to ensure that there is no discrepancy between what emerges from the discussion and what students are formally taught. The workplace teaching of professionalism must align to the formal curriculum and the set of values outlined by regulatory bodies, in order to avoid the parallel internalisation of a negative hidden curriculum. The hidden curriculum has been defined as “the commonly held understandings, customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education” (7) and it is cause of ethical erosion among students (8). In this regard, the teacher should encourage the prompt and open discussion of conflicting and “implicit” messages that students might have received during past experiences, in order to resolve any internal conflict they have. At the end of the small-group discussion, after listening and interacting with each others, students will have an enriched and multidimensional definition of professionalism, expectations of being a professional will be set, and they will be aware of the existence of a hidden curriculum that must be recognised in order to be avoided.

Role modelling influences character formation and it is essential that students are exposed to, and can be inspired by professional behaviours in real-life contexts. The teacher should explicitly state to students what behaviours are going to be modelled, in order to stimulate reflection during and after the encounter (4). Complex cases, with aspects of ambiguity and uncertainty, should be proactively sought, as these often represent a source of stress and burnout in the normal workday of a doctor (5). By being exposed to such situations, students can start learning how to cope in a professional way, and build tolerance even when multiple stressors, such as high patient’s expectations, limited resources and ethical dilemmas are present at the same time. Several areas of professionalism are concerned, for example when dealing with patients undergoing cancer treatment, and for this reason, these can be highly formative for students. These patients usually present daily challenges, such as unstable vital parameters, difficult management of pain and nausea and nutritional imbalance; in order to deal with these challenges, the doctor must demonstrate sound clinical knowledge and decision making. Excellent communication skills are equally important when liaising with the multidisciplinary team, such as nurses, nutritionists, oncologists, and palliative staff. Empathy, compassion, honesty and integrity are necessary when communicating with these patients and their relatives. Rushing through the clinical case must be avoided; students highly value, as role models of professionalism, those doctors who take the time to provide adequate information to patients and their family, who respect patient’s wishes, who are non-judgmental towards relatives, and respect all the members of the healthcare team (9).

To ensure that students make the most out of these learning opportunities, a student-centred approach must be maintained, ensuring protected time for debriefing and reflective practice. Reflective practice after a challenging clinical encounter encourages students to critically think about their values and beliefs; this is the aim of the third step of this framework. Either personal or collaborative reflection can be used here, although we encourage the use of the latter, as multiple perspectives and ideas usually provide a deeper and more enriching experience. During group reflection, students should describe with their own words what they have learned during the clinical encounter, highlighting those areas where they felt discomfort and uncertainty. Ideally, the reflection should be spontaneous and free from technicalities and didactic components; instead, allowing emotions to flow in the discussion helps students to build emotional intelligence and empathy (5). The session can be concluded by highlighting what students learned and reflected on, linked to the principles and values formally taught, ensuring that the experience gained in the ward align to the expected outcome set out by the professionalism curriculum.

In summary, a structured approach through which we can teach and role model professionalism should be sought. The proposed framework is based on evidence from the literature on how small-group discussions, role-modelling and reflective practice can help students achieve a better understanding of medical professionalism. We firmly believe that the teaching of professionalism must rely on the use of complex real cases and experiences that students can witness firsthand in the hospital environment. As suggested by Monrouxe et al. (6), such sense-making opportunities provided by real contexts can help to nurture a generation of doctors who, instead of “acting professionalism and representing the profession”, can hopefully become full-fledged medical professionals.