Shaping professionalism in pre-clinical medical students: Professionalism and the practice of medicine

Abstract

Background: Increasing emphasis is placed on teaching and assessment of professionalism in the continuum of medical education. Consistent and longitudinal instruction and assessment are crucial factors that learners need in order to internalize the tenets of professionalism.

Aim: We aimed to develop a novel longitudinal course in professionalism spanning the first 2 years in a medical curriculum.

Methods: This is a description of the process undertaken over the past 7 years to develop and implement a professionalism curriculum. We used the conceptual framework of constructivism, principles of adult learning, experiential learning and reflective practice to integrate learning with experience. We included student input in session development. Faculty mentors serve as role models to guide, assist and counsel students. Assessment of learners is accomplished using self, peer and mentor evaluation, and a student portfolio. Program evaluation is by course and faculty evaluation.

Results: Students are given a final grade of pass or fail, together with a brief narrative. Course evaluations were positive. A survey questionnaire showed that more than 60% of the students reported gaining skills related to course goals.

Conclusions: A longitudinal curriculum for the pre-clinical years was successfully launched. Plans are under way to expand this into the clinical years.

Introduction

‘What is a profession?’ This is usually the first question posed by regulatory bodies and professional societies as they consider their responsibilities to society. Writing in The Harvard Educational Review in 1953, M.L. Cogan offers this answer: ‘A profession is a vocation … founded upon an understanding of the theoretical structure of some department of learning or science, and upon the abilities accompanying such understanding … applied to the vital practical affairs of man. The practices … are modified by knowledge of a generalized nature and by the accumulated wisdom and experience of mankind … The profession … considers its first ethical imperative to be altruistic to the client.’

Beginning with Hippocrates and Maimonides, the ethical foundation of medical professionalism – the primacy of patient interest and the subordination of self-interest – has remained constant. This has led to the ‘social contract’ that exists between doctors and the public (Cruess 2006), and it is within this context that professionalism conveys its significance.

The emphasis on professionalism throughout the continuum of medical training is evident in the guidelines for medical schools (Liaison Committee on Medical Education 1998; Association of American Medical Colleges 1999; Institute for International Medical Education 2002; General Medical Council 2003), for graduate medical education (Accreditation Council for Graduate Medical Education 1999) and for professional societies (American Board of Internal Medicine Foundation 2002; American Board of Pediatrics 2000). This article will briefly review recent trends in professionalism education, and will describe a novel course developed at the Keck School of Medicine of the University of Southern California.

Table

Practice points

The teaching and assessment of professionalism should be consistent and longitudinal. Developing a professionalism curriculum that integrates learning with experience should be done in the context of theoretical learning constructs. Faculty mentors can serve the dual purpose of role modelling and providing guidance in the development of medical students as professionals. Assessment of learners includes self, peer and faculty assessment as well as reflection, and portfolios to mirror assessment methods in professional practice

Professionalism instruction and assessment

Since the 1980s, academic medicine has been committed to advancing professionalism. Professionalism instruction has traditionally taken place in the context of faculty role modelling. This role modelling, albeit a powerful method, is no longer adequate to insure the inculcation of professional attributes and values in medical students. In an increasingly complex and diverse society, more explicit instructional techniques are required (Cruess & Cruess 2006). Because both the formal and informal curriculum will influence learners, neither can be ignored (Stern 2006). The teaching of professionalism can be approached in three ways. We can teach it explicitly using specific content (Cruess & Cruess 1997; American Board of Internal Medicine Foundation 2002); we can ask learners to engage in experiential learning; or, optimally we can combine the two prior methodologies (Cruess & Cruess 2006; Steinert et al. 2007). With any of the methodologies, the instruction should be both longitudinal and consistent.

The assessment of professionalism must include gathering evidence that the intellectual foundation has been learned and that its ideals have been internalized, and must document that learners’ behaviours reflect the values of the profession (American Board of Internal Medicine Foundation 2002). Before graduating their students, medical schools must be able to verify that professionalism has been taught and assessed, and that the students have acquired the essential skills. There is evidence in the literature that feedback derived from assessment may improve professional behaviour (Papadakis et al. 2001). Therefore, since the process must be both formative and summative, assessment should begin early, be conducted frequently and at regular intervals and learners should be given the opportunity to improve (Lynch et al. 2004). Multiple methods of assessment and multiple assessors provide an ideal approach since professionalism is a complicated construct and the use of multiple methods may compensate for any weaknesses in a single approach (Ginsburg et al. 2002; Lynch et al. 2004).

Swick et al. (1999) stated that of 116 medical schools surveyed in the United States, 104 schools have made efforts to include professionalism curricula in the education and training of medical students. The Keck School of Medicine of the University of Southern California (KSOM) developed a course entitled Professionalism and the Practice of Medicine (PPM), as an essential component of a new curriculum implemented in 2001, to attend to the instruction and assessment of professionalism.

Methods

Conceptual framework

We used ‘Constructivism’ as the conceptual framework for our course. In this educational philosophy, each individual constructs knowledge as opposed to receiving it from others. Case-based learning environments and collaboration are key features of constructivist learning activities. Students are encouraged to think and explain their reasoning and education is centred on themes and concepts and the connections between them, rather than on isolated information (McBrien & Brandt 1997). As von Glasersfeld (1995) writes, ‘from the constructivist perspective, learning is not a stimulus-response phenomenon. It requires self-regulation and the building of conceptual structures through reflection and abstraction’. This course is thus based on active participation by students in problem-solving and critical thinking, whereby they ‘construct’ their own knowledge by making sense of their experiences and integrating them with pre-existing intellectual constructs. In PPM students use case-based learning, facilitated small group discussions and reflective exercises to accomplish the curricular objectives.

Professionalism and the practice of medicine

The curriculum

Professionalism and the Practice of Medicine is a required longitudinal course that spans the first 2 years of the medical curriculum, meeting on selected afternoons for 2 hours per session. There are 24 sessions in Year 1 and 16 sessions in Year 2. It was offered for the first time at KSOM in 2001–2002.

The purpose of the PPM course is to create a learning community and social context to provide, identify and facilitate learning alongside professional role models. Faculty often host students in their homes and/or have informal lunch meetings on or off campus in addition to the scheduled class time, in order to facilitate building the professional community. Students are introduced to the nature of professionalism and the ways in which it is manifested in their own lives. The PPM course encourages self-initiative and leadership in the process of learning encourages greater professional maturity, and increases sensitivity and skills in relation to professional issues in medicine such as integrity, empathy, collaboration, cultural competence and ethical decision-making. The PPM course provides students with an opportunity to build professional identity and encourages them in their learning, using study strategies such as case discussions, problem-solving and independent study. The students gain skills and competence in the broad areas of communication, social and community contexts of health care, ethical judgment, self-awareness, self-care and personal growth, professionalism and life-long learning. The curriculum is based on the principles of adult learning (Knowles 1984) is life-centred, makes use of students’ experiences in the learning and promotes self-directed learning. The course goals are listed in Table 1.

Table 1.  Course goals

• Develop and promote professionalism, ethics, empathy, reflection, cultural competence, communication skills and collaborative learning.

• Create and maintain community and a social context to provide identity and facilitate learning.

• Provide professional role models for students to emulate.

• Prepare students to work collaboratively and increase their small group skills.

• Provide students with an opportunity to build professional identity.

• Encourage students in their learning, reflection, peer and self-evaluation.

• Introduce students to the nature of professionalism.

• Provide opportunities for students to gain skills and demonstrate competence in the areas of communication, social and community context of health  care, ethical judgment, self-awareness, self-care and personal growth, professionalism and life-long learning.

• Provide opportunities for students to gain skills and demonstrate competence in the areas of communication, social and community context of health  care, ethical judgement, self-awareness, self-care and personal growth, professionalism and life-long learning.

• Encourage students to demonstrate self-initiative and leadership skills when leading and presenting to the group.

• Prepare students for transition to Year 3.

Course design

The PPM structure takes advantage of intact Introduction to Clinical Medicine (ICM) and gross anatomy student groups. Each ICM and gross anatomy group is comprised of the same six students; four of these six-member groups form the learning communities, made up of 24 student members. Through PPM, students are prepared to work collaboratively and increase their small group skills to improve their competence in ICM, gross anatomy laboratories and other learning community activities.

An innovative approach – the use of faculty mentors – was also introduced. Since the days of the Trojan War, when Odysseus left mentor in charge of his son, Telemachus, as he left for battle, there have been many accounts of mentoring in fact and fiction, science, medicine, business, education and law. Some famous mentor/mentee pairs include Socrates and Plato, Haydn and Beethoven, Sigmund Freud and Carl Jung. The original mentor served as an experienced and trusted guide, a teacher and counsellor to Telemachus, and it is this sort of relationship that Levinson (1978) writes about in his book, The Seasons of a Man's Life. The mentoring relationship, he says, is one of the ‘most complex and developmentally important’ in a person's life. Levinson does not see the relationship in formal terms, such as ‘teacher/student’ or ‘boss/subordinate’, but rather in terms of its character and its functions. Several functions are considered integral in the mentoring relationship: teaching, sponsoring, guidance, socialization into a profession, provision of counsel and moral support. The function of the mentors in PPM is to guide, assist and counsel students longitudinally in their development as professionals. There is a highly selective process that takes place in choosing extremely skilled, well-respected faculty to serve as mentors and an ongoing robust faculty development program to hone and refine their skills as mentors. There are two faculty mentors for each learning community for the duration of the 2 years of students’ pre-clinical education. Vygotsky's theory of scaffolding and zone of proximal development serve as underpinning for the use of mentors (Miller 1995). Scaffolding occurs as the mentor(s) continually adjusts the level of his or her help in response to the learner's performance. The concept of the zone of proximal development is that the range of skill that can be developed with guidance by the mentor exceeds that which can be attained by the student alone.

The mentors also serve as role models, exemplars of practicing professionals who function in a real-world context. Inui (2003), in A Flag in the Wind: Educating for Professionalism in Medicine, has stated that role modelling has the most powerful influence on professionalism. In our course, faculty mentors are selected based on their teaching expertize and ability to effectively mentor students. Their willingness to commit time and energy to accomplish the goals of the curriculum, their professional maturity and depth and breadth of experience are key. They must be willing to share personally to build rapport and to serve as role models for the students. Additionally, mentors must have group process skills that allow for building a learning community, and the ability to create opportunities for personal and professional effectiveness. Finally, the faculty mentors must have a passion for creating an experience that is challenging, formative and memorable. Our faculty mentors include our Senior Associate Dean for Educational Affairs and our Associate and Assistant Deans for Curriculum, Student Affairs and Admissions. Directors of the ICM and PPM courses, along with full time and voluntary faculty members complete the mentor team.

Course activities

In each of the 2 years, the PPM course has several modules or content themes. These include professional development, cultural competence, ethics, health care policy, physician well being and group process. A list of 2007–2008 PPM sessions are delineated in Table 2.

Table 2.  Curricular themes

Professionalism

• Beginning our professional journey: symbol & ritual

• Professionalism in action: threats to professionalism

• Physician well-being

• Nuts & bolts of medical practice

• Physician satisfaction and physician impairment

Cultural competence

• Introduction to culture and its role in medicine

• Screening the soul: spirituality in medicine

• Herbs, vitamins, and botanicals

• Integrative medicine: CAM practitioners

• Health care disparities

• Gang cultures of East Los Angeles

• Healthcare for LGBTQ patients

• Patients with substance abuse

• Effective use of medical interpreters

• Caring for patients with disabilities

• The physician's role in community advocacy

• Community diagnosis

Health policy

• Healthcare legislation

• Paying for healthcare

• Public health

Ethics

• Introduction to ethical principles

• Principles of ethical decision-making

• Ethical decision-making: when values clash

• End of life-treatment ethics

Empathy

• The art of medicine

• Narrative medicine

Group process

• Sharing our stories

• Effective teamwork

Specific goals and objectives for each session are identified and a prototype of a schedule, or session script, is distributed to all PPM faculty mentors, which includes any pre-session assignments or required/suggested readings. A typical script identifies a faculty resource person who has content expertize. For topics that require foundational content that the individual faculty mentors cannot consistently provide, the lecture hall introduction sets the stage for the self-directed learning that follows in the learning communities. Approximately half of the sessions start with such a lecture hall presentation or discussion, and the others are held in their entirety in the learning community. For many of the activities in the learning community, the students address concepts or hold discussions about particular topics as a six-member small group, and then the entire learning community of 24 students reconvenes for a wrap-up discussion. Table 3 contains a typical PPM script, which includes suggested make-up assignments for the students who miss a session, and delineates the items that are to be included in the students’ PPM portfolio.

Table 3.  A typical session

Professionalism I: Beginning our professional journey: Symbol and ritual

Faculty Resource: Dr Reilly

Session goals:

• Introduce the importance of professionalism as part of physician training.

• Discuss the white coat and its history as a symbol of their medical journey.

• Study the relevance of the Hippocratic Oath to modern medicine and review the KSOM Code of Professional Behaviour.

• Have students explored their commitment to the medical profession and the professional qualities they hope to embody as a physician.

Session outcomes:

By the end of the session students will be able to:

• Discuss the philosophy of professionalism at KSOM and in the profession of Medicine.

• Describe ways to exhibit attributes of professionalism in their daily lives.

• Develop their personal Hippocratic Oath as it relates to their own concept of medical professionalism.

• Self-reflect on their personal medical journey and their expectations of themselves, their classmates and their medical training as part of this professional development.

Pre-session assignment:

Students are to write their own Hippocratic Oath. Each individual student's one-page oath is to be e-mailed to both PPM mentors.

Pre-session readings:

(1) KSOM Code of Professional Behaviour

(2) The abridged Hippocratic Oath

Discussion:

The necessity to teach professionalism in the medical school curriculum has been the subject of numerous recent publications. The purpose of this session is to specifically introduce the students to the concept of what is meant by a profession, describe what behaviours are expected of medical professionals, to provide a forum and opportunity for the student to reflect on what brought them to medical school and on what kind of personal and professional attributes they hope to embody as a physician. Specifically, the issue of how they will behave in their professional community will be addressed. They will discuss the symbols and rituals they have just experienced as part of the White Coat Ceremony as part of their professional development.

Introduction to professionalism—Dr Reilly—Lecture hall

Dr Reilly will begin a discussion of the medical journey and the symbols and rituals that are part of that journey beginning with the white coat. She will also introduce the concept of professionalism and its significance in their medical training and daily lives. The session will utilize clips from ‘Patch Adams’ and ‘The Doctor’

Case discussion on professionalism and the White Coat – Learning community

Potential questions to start the discussion include:

• Were Jack McKee MD, and/or Patch Adams good examples of professional behaviour? Why or why not?

• How does your own Hippocratic Oath compare with the behaviour demonstrated by the doctors in the movie?

• What personal and professional attributes will you cultivate to enhance professional behaviour?

• What will be your biggest challenge in cultivating a professional identity?

• How do groups cultivate a professional identity?

• How will this learning community impact the professional development of its members?

Learning community code of conduct – Small groups in the learning community

Students will work together in their small groups to construct a suggested code of conduct for their learning community. Utilizing discussion, while referring to the KSOM Code of Professional Behaviour, students will develop a set of standards for behaviour in the learning community. A leader from each small group will share their suggestions with the entire learning community for synthesis into a working document.

Learning community code of conduct – Learning community

Group leaders from each small group will present their groups recommendations for the learning community code of conduct. Items of agreement should be solidified, differing issues debated and compromise achieved. Students should be reminded that this is a preliminary discussion, and that the process is expected to continue outside of PPM. It is expected that students will use independent time to meet as a group to complete this task. The outcome of this assignment is a code of behaviour for their learning community for the next 2 years. It should be a document that everyone is willing to abide.

Portfolio: (1) Individual Hippocratic Oath. (2) The learning community Code of Behaviour will be posted in the MDL and included in each student's portfolio.

In Year 2, the majority of the sessions are student led. Groups of three or four students serve as the discussants session leaders. The faculty mentors are present serving as facilitators and provide feedback to the student leaders to aid in their professional development. This format allows the students to engage more deeply in a topic of interest, to them and allows them to develop their leadership and presentation skills in preparation for the clinical years of medical school and beyond. Prior to their leadership of a PPM session, the students meet with the faculty expert to discuss the goals and objectives of the session, to have the faculty member answer any questions and to review the suggested session script. Students may modify the script to incorporate their particular interests or expertize but must gain the approval of the faculty expert to insure that the revised plan meets the session goals.

Students continue to be instrumental in developing new sessions, independently or alongside a faculty member. A student recently brought an idea for a session on the needs of disabled patients to the course directors. Working with the student and content experts, the PPM course directors developed and implemented the session, ‘Caring for Patients with Disabilities’. This is just one of the many examples of the ongoing practice of having students actively involved in PPM course development and delivery.

Assessment

Criteria for satisfactory completion of PPM includes: (1) attendance at all sessions, (2) satisfactory completion of all required activities, (3) completion of all PPM course, mentor and peer evaluations by the stated deadlines and (4) professional behaviour towards colleagues, faculty, patients and staff per the KSOM Code of Professional Behaviour. Professional behaviour encompasses integrity, respect, courtesy and compassion in a pattern of moral and ethical interactions with guests, peers, faculty and staff. It requires confidentiality and responsibility regarding patient information and group discussions and demands an understanding of and esteem for oneself, as well as guests, peers, faculty and staff. Any missed session requires completion of a make-up assignment arranged with the PPM mentor(s). This may include a standardized make-up assignment outlined in the session script, report of research on a selected learning issue or a special essay or project at the discretion of the PPM mentor(s).

Student evaluation

The evaluation system for PPM consists of self-reflection and self-assessment, peer assessment and feedback, faculty feedback and evaluation (structured and informal), and a student portfolio.

Our activities centre on the understanding that professionalism is promoted by reflection on experiences. Leach (2004) states that ‘acquiring competence in professionalism is developmental, proceeds along a continuum and is nurtured by reflection on experiences’. Students are asked two or three times during the year to reflect on their learning in relation to areas of focus (e.g. group process, professionalism, cultural competency and ethics). The application of lessons learned in PPM to their own clinical experiences in ICM, serves as the basis for these reflective assignments. They are challenged to identify individual learning points, personal areas of weakness, areas for growth and plans for how they will continue to become more competent. Students also complete a self-assessment form, twice during Year 1 and once during Year 2, and write several paragraphs describing their professional growth, strengths, weaknesses and plans for development at each of these prescribed points in their training.

The literature suggests that students are able to conduct a reliable evaluation of their peers (Arnold et al. 1981). Peer-rating forms have been found to be able to have good inter-rater agreement in measuring aspects of professional behaviour (Davis & Inamdar 1988). Leach (2002) notes that peer assessment ‘offers the benefit of professional self-regulation and accountability’. In PPM, a formal Peer Assessment process takes place twice per year, allowing students to provide feedback to peers in their small group. The focus of this assessment is on communication, self-awareness, self-care and personal growth and on professionalism as reflected by behaviours within the small group. Professionalism in this non-clinical setting includes behaviours such as punctuality, respectful behaviour towards peers and faculty, completing assigned tasks, being supportive to team members and admitting when you do not know something. As part of the assessment of the performance of each small group, students are encouraged to share their self-assessments and peer-assessments with each other.

Portfolios have been shown to increase learning in undergraduate medical students in cancer education (Finlay et al. 1998) and the use of portfolios in medical education is well established (Snadden & Thomas 1998). In PPM, students are required to submit a PPM portfolio that serves to document their progress and development through the course of study. Students are responsible for assembling and maintaining their portfolios. The students submit the portfolios prior to each of the individual feedback or evaluation meetings with the faculty mentors for their review. A Year 1 portfolio table of contents is presented in Table 4.

Table 4.  Table of contents of Year 1 portfolio

Fall Semester
Portfolio Item	Session*
Autobiography	2
Individual Hippocratic Oath document (pre-session assignment)	3
MDL oath (final version)	4
Lifestyle Wheels	5
Health contract (signed and dated)	5
Community Diagnosis (pre-session assignment)	6
Myers–Briggs Personality Inventory	8
Student writing – individual spiritual assessment and reflection using HOPE model (pre-session assignment)	10
Self-evaluation exercise	11
Self-assessment assignment	11
MSPE Advisory Committee Professionalism Assessment Form (copy of completed evaluation submitted for ICM)
Spring Semester
Portfolio Item	Session**
Student writings – narrative writing	14
Self-reflection: cultural competence	14
Student writings – ethical dilemma (pre-session assignment)	17
Self-reflection: ethics	18
Self-evaluation exercise	19
Self-assessment assignment	19
Curriculum vita	19

Notes: *The portfolio will be reviewed with students at their mid-year evaluation session.

**The portfolio will be reviewed with the student at their year end evaluation session.

Mentor feedback and evaluation involves both formative coaching and summative evaluation. The feedback process is not directly connected to evaluation in that feedback represents attempts to ‘coach for excellence’, while evaluation measures basic willingness to attend, participate and perform appropriately (e.g. complete all assignments and make constructive input to the group). Mentors discuss the students’ performance with them twice per year. The mid-year evaluation helps focus the good or excellent student so s/he can improve in one or two critical areas, and alerts the failing student to that fact and outlines specific steps needed to correct behaviour. The KSOM professionalism objective and the related behavioural outcome measures are listed in Table 5. Thus by bringing the School's educational program objectives and our Code of Professional Behaviour into the explicit curriculum of the PPM course, evaluation in this domain becomes more of a lived experience for our students, rather that a merely theoretical construct.

Table 5.  Educational program objectives and learner outcome objectives

Professionalism – Demonstrate altruism in interactions with patients, colleagues, faculty and staff. Act with honour and integrity in professional and personal life. Demonstrate caring and compassion for patients and for members of the healthcare team. Respect patients’ rights and wishes, and act in a respectful manner towards faculty, colleagues and staff. Act responsibly in his/her professional and personal life. Pursue excellence in scholarship, assuming responsibility for addressing gaps in knowledge. Model good leadership in interactions with others, and foster others’ development.	• Demonstrates reliability, dependability, integrity, courtesy and self-discipline in the classroom and with their small group in all learning settings.	• Recognizes and can describe own role and the roles of other members of the team.
• Demonstrates emotional maturity, recognizes issues in interaction and is able to appropriately resolve tensions and conflicts.	• Recognizes and can discuss with knowledge legal and ethical issues in health policies and in own patient care experiences.
• Demonstrates leadership in both large and small group activities.	• Demonstrates the pursuit of excellence in individual activities in PPM and in those of the group.
	• Demonstrates leadership in both large and small group activities.

The end-of-year summative evaluation provides a final ‘grade’ (pass or fail) for the student along with a brief narrative that goes into the permanent record for that student and in the student's Medical Student Performance Evaluation (MSPE). Only two students have failed PPM since the course's inception. These students did not meet minimal expectations in the areas of professional behaviour and respect for their mentors and peers. Individual feedback sessions can be scheduled at the request of student or mentor any time during the year. Comments will be made from time to time to students as appropriate to provide constructive feedback as to how each might want to focus attention on certain issues.

Program evaluation

Evaluation of the professional development curriculum includes both a course and faculty evaluation. Students evaluate each faculty member individually (twice in Year 1 and once in Year 2) and they evaluate the individual sessions both for their overall quality and the effectiveness of increasing understanding or building skills. Both instruments use a five-point Likert scale for each item: strongly agree to strongly disagree. Narrative comments and suggestions for improvement are part of each item set.

Overall, the course evaluations are positive. The student ratings of the sessions range from 3.51 to 4.63. Among the most well-received sessions are those where outside guests, such as patients dealing with substance abuse or former gang members from the local community, share their experiences with the learning community. Additionally, charismatic speakers, such as an oncologist who discusses the art of medicine or a community leader who speaks about the physician's role in community advocacy, have been highly rated.

Faculty evaluations average 4.59 for Year 1 and 4.66 for Year 2. The PPM faculty mentors are highly regarded by the students and serve as resources for them throughout medical school and beyond. Comments indicate that students appreciate the time and commitment of the faculty and believe that the faculty's interest in their well-being is genuine.

Focus groups are held twice yearly with PPM group representatives. Two representatives per learning community are selected by their peers to represent them. The students meet with the course directors and review each session and make suggestions for improvement.

In the early years of the new curriculum, students were asked where in the curriculum they had gained skills in relation to each of the Keck Educational Objectives. Over five administrations of the form a high percent of students indicated PPM for each of the following goals – communication skills (75.7%), social and community context of health care (78.2%), ethical judgment (81.2%), self-awareness, self-care and professional growth (76.2%) and professionalism (79.1%).

The development of the current course has been a 7-year journey. The PPM course has been shaped by the program evaluation data mentioned above and by changes in the curricular recommendations and requirements of our accreditation body, the Liaison Committee on Medical Education (LCME).

Conclusions

We have developed, delivered and evaluated a course that fosters the professional development of our medical students. Faculty members have become engaged and invested in the personal and professional journey of our students. Valuable tenets such as mentoring, learning communities, professional development, portfolios and peer evaluation have become institutionalized at KSOM as a result of PPM. Expanded topics such as cultural competence, group process, health care policy and finance and physician well-being have been incorporated as core curricular content.

We have learned that creating and maintaining a new curriculum that brings ethics, empathy, professional development, communication skills and cultural competence to pre-clinical students is a challenging task. Our success lies in the fact that students have developed bonds with each other and with faculty mentors and have gained a deeper understanding of a variety of professional issues. We continue working to improve mentor skills through faculty development, and to optimize topic selection, session format and session delivery. Since professionalism is such an integral part of medical education, we also have plans to expand this course into the clinical years as part of an upcoming Years 3 and 4 curriculum revision.

Anecdotal comments from Years 3 and 4 students and KSOM alumni indicate that they appreciate the skills they gained in PPM and recognize that these skills are essential characteristics required of successful physicians. Hirsch (2007), a Keck alumnus, writes this about PPM: ‘Initially, it was somewhat difficult for me to understand the importance of these [PPM] sessions. I appreciated our instructor's intentions but often felt that the materials could have been more effectively presented …. After several months of research and discussions with my mentors, I began to understand that our professionalism course was building a base of knowledge and experience for us to use when relating to patients …. Although students may not immediately see the value of this type of education, it is to our benefit that my generation of physicians is specifically instructed in empathy and professionalism’.

As Inui (2003) says, ‘[Our] most difficult challenge [is to be] mindful of, and articulate about – medical education as a special form of personal and professional formation that is rooted in the daily activities of individuals and groups in academic medical communities’. The PPM course at Keck School of Medicine represents one aspect of our school's effort to institutionalize this type of active, ‘daily’ professionalism education. Through engagement with faculty mentors in learning communities in the first two years of medical school, our students learn to think critically and to reflect on what it means to become a physician – to become part of the profession of medicine.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Notes on contributors

Donna D. Elliott

DONNA ELLIOTT, MD EdD is Associate Dean for Student Affairs and Associate Professor of Pediatrics at the Keck School of Medicine of the University of Southern California. She served for 3 years as course director for PPM. Dr Elliott's interests are cultural competence and professionalism education.

Win May

WIN MAY, MD PhD, is Associate Professor in the Division of Medical Education, Department of Pediatrics at the Keck School of Medicine of the University of Southern California. Her special interests are standardized patient feedback, professionalism, assessment of clinical performance, clinical reasoning, faculty development and emotional intelligence.

Pamela B. Schaff

PAMELA SCHAFF, MD, is Associate Professor of Pediatrics and Family Medicine at the Keck School of Medicine of the University of Southern California. She is Assistant Dean for Curriculum and Student Affairs and Director of Keck's Program in Medical Humanities, Arts and Ethics.

Julie G. Nyquist

JULIE G. NYQUIST, PhD, is a Professor in the Division of Medical Education of the University of Southern California. She directs the Master of Academic Medicine program. Dr Nyquist serves as program evaluator for the medical student curriculum at the Keck School of Medicine.

Janet Trial

JANET TRIAL, EdD, is an Instructor at the Keck School of Medicine of the University of Southern California. Currently, she is Co-Director of the PPM Course. Additionally, she is Project Manager for the Enhancement of Cultural Competence Education Project at Keck School of Medicine.

Jo Marie Reilly

JO MARIE REILLY, MD, is Associate Professor of Family Medicine at the Keck School of Medicine of the University of Southern California. She is currently Co-Director of the PPM course and Assistant Director of the ICM Course.

Patrick Lattore

PATRICK LATTORE, PhD, served as the faculty coordinator of the Leadership Fellowship program in the Division of Medical Education at the Keck School of Medicine of the University of Southern California. Dr Lattore envisioned and executed the development of the PPM course.