Abstract
Developing and assessing professionalism in medical students is an international challenge. This paper, based on preliminary research at the Faculty of Medicine and Dentistry of the University Sapienza of Rome, Italy, briefly summarizes the main issues and experiences in developing professionalism among Italian undergraduate medical students. It concludes with a proposed framework suited to the Italian medical curricula. In our educational system, professionalism is defined as the context of medical expertise, the combination of rules, conditions, and meanings in which the act of health care occurs, as well as the ability of critical reflection on technical expertise. It is a multidimensional construct of ethical, sociocultural, relational, and epistemological competencies, requiring a wide range of tools for assessment. With reference to Italian versions of validated tools of measure, vignettes, videos, and a student’s portfolio of reflective writings, this paper outlines the manner in which education for professionalism is embedded in the existing curriculum and overall framework of assessment.
Introduction
Defining professionalism and explicitly integrating professionalism into the medical curriculum presents a difficult challenge.Citation1,Citation2
While there is a general consensus regarding a set of elements that are components of professionalism,Citation3 their exact determination remains elusive. Aside from being a set of personal traits, professionalism can also be conceived as the expression of the relationship between the profession and the social and cultural context in which health care professionals function.Citation4 One of the recommendations of the International Working Group on Professionalism is to “examine the concept of professionalism and its assessment across different linguistic and cultural contexts”, raising the issue of intercultural comparison of curricula.Citation5
The purpose of this article is to present the initial experiences at the Faculty of Medicine and Dentistry of the University Sapienza of Rome, Italy, where an educational framework for the development of professionalism, suited to the structure of the Italian medical curriculum, was implemented.
Background and principles of design and methods
The Faculty of Medicine and Dentistry of the University Sapienza of Rome maintains traditionally designed curricula in medicine, nursing, and other allied health care professions. Medical training lasts 6 years and is divided into three 2-year periods: basic, preclinical, and clinical. A medical education committee identifies and discusses problematic areas in teaching/learning to propose solutions. A working group, composed of the authors of this paper, was in charge of designing a curriculum for the development of professionalism.
Based on the concept of “spiral learning”, the foundation of the design is the vertical integration of learning of professionalism throughout the formal curriculum.Citation6 A special stream of courses, prefixed as methodology, is offered in all 6 years of the curriculum. These courses only partially relate to the acquisition of specific technical knowledge or skills. In addition, they focus on the general ability to use knowledge to set and solve problems (). This stream appeared as the most obvious framework to provide structure to a vertical curriculum addressing the development of professionalism.
Table 1 The stream of methodology courses at the Faculty of Medicine and Dentistry of Sapienza University of Rome, Italy
A second core concept in design was “assessment for learning”.Citation7 Quantitative and qualitative information from multiple sources is needed to assess a complex competency. Therefore, we paid special attention to a variety of assessment tools that address different components of the overall construct of professionalism.
We intended this construct as a multidimensional set of competencies:
ethical competence: with regard to clinical ethics and bioethics;
sociocultural competence: with regard to sensitivity to community, multiculturalism and the social contract, as well as the contributions of sociology and anthropology;
relational competence: with regard to the relationship with self, with colleagues in a team, and with patients; and
epistemological competence: with regard to the use of evidence and critical thinking as well as the ability to cope with complexity.
In our view, professionalism is the context of medical expertise, as a combination of rules, conditions, and meanings in which the act of health care occurs. Additionally, professionalism encompasses the ability of critical reflection on technical expertise. It is expressed through the ability to act and make decisions when dilemmas or elements of complexity are present.
This approach and the interim results of the design were discussed in an iterative process with the medical education committee and coordinators of the methodology courses.
Results
As mentioned above, the stream of methodology courses already demonstrated a close congruence with the elements and skills necessary for the development of professionalism. summarizes some of the most relevant objectives for the growth of professionalism, already present in the courses. Currently, our curriculum is comprised of lectures, small group tutorial activities, and practice. Therefore, we did not introduce new contents but emphasized to both students and teachers that the goal of the curriculum was the development of a mature medical professional ready to meet today’s health care challenges in Italy. This was accomplished by illustrating the new framework to the methodology course teachers in a series of meetings. The framework was also explicitly detailed in the official guide for students. Finally, the most relevant element in the enhancement of awareness was the introduction of a systematic series of assessments throughout the 6 years based on the set of tools we identified.
Table 2 Examples of learning objectives identified as relevant in the framework of professionalism for the stream of methodology courses at the Faculty of Medicine and Dentistry of Sapienza University of Rome, Italy
We began the assessment of professionalism traits in students during the first year because expectations, knowledge, and attitudes of students at the beginning of their studies are often not perfectly aligned with the real needs and practise of health care today.Citation8 With this goal in mind, we selected, translated, and adapted three instruments from international literature, with authors’ permission, and revalidated them in an Italian version. The selected instruments were designed to measure the knowledge and attitudes towards sociocultural competence,Citation9 empathy,Citation10 and the interactions with self, patients, colleagues, and institutions.Citation11 The validation study was conducted on 90 first-year students. summarizes the structural and psychometric characteristics of the three instruments, which proved to be valid and reliable even in the Italian adaptation. Specifically, for each instrument, a reliability index was expressed as Cronbach’s α. This index measures the degree of internal consistency of an instrument. An α-value above 0.6 is considered acceptable for experimental use, while a value greater than 0.8 indicates excellent performance, which allows for the routine use of the instrument. The overall educational framework also included a yearly reassessment with the same instruments. From the third year on we will also use vignettes and a Professionalism Mini Evaluation Exercise (P-MEX).
Table 3 Structure and psychometric characteristics of the three instruments, translated and adapted for Italy
The use of vignettes to contextualize ethical dilemmas is a method of challenging students’decision-making ability and to measure their proposed behavior.Citation12 The vignettes can be written or videotaped scenarios.Citation13 We wrote ten vignettes addressing problematic situations using the Italian Code of Professional Ethics of the Italian Federation of Medical Colleges as a reference. We also translated into Italian five short videos used in an international study on the cross-cultural comparison of students’ approaches to professional dilemmas.Citation14 Written and video vignettes will be used in small group tutorial sessions to foster reflection and provide formative assessment.
The Mini Clinical Examination ExerciseCitation15 is a well-known method of clinical performance-based assessment in which a student–patient encounter is observed and assessed by a grid. This method was developed to encompass the assessment of professionalism and was then named the P-MEX.Citation16 The evaluation is based on short interactions (about 5 minutes) that occur frequently during training so that each student can be evaluated on several occasions by different faculty members. The P-MEX was created as an advanced exercise and assessment method for use during the clinical years.
A final method of assessment will be the systematic introduction of a portfolio of professionalism for third- to sixth-year students. It is intended to collect their narratives and reflections about their performance of practical activities. Portfolios have been used for many years as a means of collecting reflections of students’ first clinical encounters with patients during the third year.Citation17 We are now ready to expand its use through all preclinical and clinical years. As already noted, the main mechanism for development of professionalism is reflective thinking. Portfolios have proved to be particularly effective in promoting reflection,Citation18 provided they are properly considered and valued by teachers and not dismissed as an accessory, marginal to the dynamics of learning and assessment.
Discussion
The concept of a profession was clearly distinguished from the more general category of a job almost 60 years ago in sociology literature.Citation19 However, up until about 30 years ago there were no articles in the medical literature explicitly addressing the issue of professionalism. Many papers dealt with educational concepts defined as “noncognitive” or “interpersonal skills”, but only in the late 1980s did reflection on the elements and characteristics of medical professionalism become explicit.Citation20 One of the most updated definitions of professionalism considers it a social contract based on trust and mutual respect between health care professionals and patients, despite the asymmetry of the relationship.Citation4 If rooted in a social contract, professionalism is a cultural construct subject to the influence of location and time.Citation21 Therefore, an educational framework for the development of professionalism must be tailored to the local cultural context.
We designed a framework rooted on the principles of longitudinal integrationCitation6 because we wanted to overcome the traditional approach to training through an implicit process of learning by example (role modeling). In this approach, students are exposed to the conduct of their teachers and theoretically develop typical attributes of the profession based on teacher behavior. In a complex multicultural society, however, this training model is not appropriate.Citation22 A training process is needed that includes explicit iterative reflection that is distributed throughout the course of studies with a transdisciplinary involvement of the entire faculty.Citation23 The preferred training method is a combination of reflective thinking on the activities and experience of the student accompanied by a stream of formative assessments.Citation24
Another feature of our design was the concept of assessment for learning.Citation7 We agree that the overall assessment program is more important than the individual tools, as suggested by the Ottawa 2010 Conference recommendations.Citation5 The most recent systematic review on the assessment of professionalismCitation25 identified five major themes under which professionalism can be classified. Nine main types of assessment tools were also identified and the authors proposed a blueprint in which one or more types of suitable evaluation tools were associated with each element of professionalism. The tools we selected and developed are in tune with this approach, and in , we illustrate an example of how some learning objectives relevant for professionalism can be matched with the various assessment tools. The results are presented in an adaptation of the classic Miller’s pyramid of progression from knowledge to competence.Citation26
Figure 1 The adaptation of the pyramid of Miller model to assess professionalism. (A) Examples of objectives relevant to progressive levels of professional competence. (B) Examples of pertinent assessment tools.
![Figure 1 The adaptation of the pyramid of Miller model to assess professionalism. (A) Examples of objectives relevant to progressive levels of professional competence. (B) Examples of pertinent assessment tools.](/cms/asset/f17dba81-7029-48fb-b7d8-fb6d7f3ddee8/dame_a_31228_f0001_b.jpg)
Although we did not introduce any new content, we placed a special emphasis on certain areas that are more relevant in Italy. Firstly, Italy is rapidly becoming a multiethnic country, giving the development of sociocultural competence in medical students a high priority. Secondly, the Italian health care system is public and universal with an elevated level of complexity. Therefore, Italian physicians must be intimately aware of its organization and procedures to direct patients towards the appropriate path.
Conclusion
The overall process of design and implementation of the educational framework for professionalism is still in progress. It is undoubtedly – as stated by GoldsteinCitation23– “an institutional challenge” which calls for a close coordination of what is already performed together with a special focus on continuous, formative, and multidimensional assessment of students. However, this requires not only substantial organization and planning but also faculty development and allocation of human resources.
The results of the initial round of assessment during the first year are not significant in themselves because we have no other reference by which to compare and interpret the results. In addition, due to varying cultural contexts, comparing the absolute values of the three scales used in this study with similar studies in other countries is not meaningful. Nevertheless, we expect relevant information from the follow-up of students, both in terms of normalizing values for the Italian version of the scales and identifying trends in evolution of the constructs. Aside from being important information for personal feedback to each student, these results could suggest improvements for the whole framework in an iterative process of refinement. The results will also be an important topic to be addressed by faculty development programs.
Disclosure
The authors report no conflicts of interest in this work.
References
- Working Party of the Royal College of PhysiciansDoctors in society. Medical professionalism in a changing worldClin Med200556 Suppl 1S5S40 Available from: http://bookshop.rcplondon.ac.uk/Accessed March 26, 201216408403
- O’SullivanHvan MookWFewtrellRWassVIntegrating professionalism into the curriculum: AMEE Guide No 61Med Teach2012342e64e7722289014
- ArnoldLAssessing professional behavior: yesterday, today, tomorrowAcad Med200277650251512063194
- CruseeSCruessRLSteinertYLinking the teaching of professionalism to the social contract: a call for cultural humilityMed Teach20103235735920423251
- HodgesBDGinsburgSCruessRAssessment of professionalism: recommendations from the Ottawa 2010 ConferenceMed Teach201133535436321517683
- HardenRMWhat is a spiral curriculum?Med Teach199921214114321275727
- SchuwirthLWVan der VleutenCPProgrammatic assessment: from assessment of learning to assessment for learningMed Teach201133647848521609177
- BlueAVCrandallSNowacekGLuechtRChauvinSSwickHAssessment of matriculating medical students’knowledge and attitudes towards professionalismMed Teach20093192893219877866
- TangTSFantoneJCBozynskyMEAdamsBSImplementation and evaluation of an undergraduate sociocultural medicine programAcad Med20027757858512063207
- HojatMGonnellaJSNascaTJMangioneSVeloskyJJMageeMThe Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item levelAcad Med200277Suppl 10S58S6012377706
- TrompFVernooij-DassenMKramerAGrolRBottemaBBehavioural elements of professionalism: assessment of a fundamental concept in medical careMed Teach20103216116920163233
- GoldieJSchwartzLMcConnachieAJollyBMorrisonJCan students’ reasons for choosing set answers to ethical vignettes be reliably rated? Development and testing of a methodMed Teach200426871371815763875
- GinsburgSLingardL‘Is that normal?’Pre-clerkship students’approaches to professional dilemmasMed Educ201145436237121401684
- HoMJLinCWChiuYTLingardLGinsburgSAcross-culturalstudy of students’approaches to professional dilemmas: sticks or ripplesMed Educ201246324525622324524
- NorciniJJBlankLLDuffyDFortnaGSThe Mini-CEX: A method for assessing clinical skillsAnn Intern Med200313847648112639081
- CruessRMcIlroyJHCruessSGinsburgSSteinertYThe Professionalism Mini-evaluation Exercise: a preliminary investigationAcad Med200681Suppl 10S74S7817001141
- ConsortiFPotassoLMilazzoFA single, collective midterm feedback can stimulate students’ reflective attitudeProceedings of AMEEAugust 30–September 3, 2008Prague, Czech Republic: Dundee: AMEE; 2008:49 Available from: http://www.amee.org/index.asp?llm=27Accessed March 26, 2012
- BuckleySColemanJDavisonIThe educational effects of portfolios on undergraduate student learning: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No 11Med Teach200931428229819404891
- WilenskyHLThe professionalization of everyoneAm J Sociology196470137158
- KrevansJRBensonJAJrEvaluation of the humanistic qualities in the internistAnn Int Med1983997207246638731
- CavicchiIL’atto medico tra il paradigma della malattia e il paradigma della salute. [Medical act between the paradigm of illness and the paradigm of health]BiancoACento Anni di Professione al Servizio del Paese [One Hundred Years of Profession to Serve the Country]RomeFNOMCEO2010 Available from: http://portale.fnomceo.it/PortaleFnomceo/showVoceMenu.2puntOT?id=67Accessed March 26, 2012 Italian
- ElliottDDMayWSchaffPBShaping professionalism in pre-clinical medical students: Professionalism and the practice of medicineMed Teach200931e295e30219811137
- GoldsteinEAMaestasRRFryer-EdwardsKProfessionalism in medical education: an institutional challengeAcad Med2006811087187616985343
- HawkinsREKatsufrakisPJHoltmanMCClauserBEAssessment of medical professionalism: who, what, when, where, how, and … why?Med Teach20093134836119404894
- WilkinsonTJWadeWBKnockLDA blueprint to assess professionalism: results of a systematic reviewAcad Med200984555155819704185
- MillerGEThe assessment of clinical skills/competence/performanceAcad Med199065Suppl 9S63S672400509