Professionalism

1. Professionalism David Taylor

2. Research question • What do medical students and Doctors understand by the term “professionalism”? • This matters because medical students • are expected to develop as professionals • are tutor assessed • Does their understanding change during their training? • Does Perry apply? • Dualism, relativism, comfort • Can we influence the rate of development? • Can we develop an inventory, or use an existing one? • Would peer assessment work?

3. What is known • Scribonius 47CE • The profession of medicine is defined as a commitment to compassion or clemency in the relief of suffering. • Pellegrino 2002 • A profession is a public statement of commitment • The doctor and the patient are in a covenantal relationship Pellegrino, E.D., Professionalism, profession and the virtues of the good physician. Mt Sinai J Med, 2002. 69(6): p. 378-84 Philosophical discourse

4. RCP Definition • Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors • Royal College of Physicians, Doctors in Society:Medical professionalism in a changing world. 2005, RCP: London. Interviews and expert group analysis

5. RCP Description • Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.

6. Doctors are committed to: • Integrity • Compassion • Altruism • Continuous improvement • Excellence • Working in partnership with members of the wider healthcare team.

7. Justice Potter Stewart • I know it when I see it. • obscenity

8. Attitudes and values Professional qualities Professional behaviour Professional habits Professional attitudes Professional demeanour Professional attributes/traits Personal qualities/personality Personal characteristics Psychosocial factors Hard to assess Non-cognitive factors Cohen 2001 • Cohen, R., Assessing professional behaviour and medical error.Med Teach, 2001. 23(2): p. 145-151. Cohen calls for direct observation of clinical performance – but what criteria?

9. Association for Surgical Education: Clinical Evaluation Protocols for Medical Students, 1985.

10. Larry Gruppen,(2005) Michigan Gauger, P.G., et al., Initial use of a novel instrument to measure professionalism in surgical residents. Am J Surg, 2005. 189(4): p. 479-87. expert group analysis

11. Van de Camp(2004) • Medline search using Cohen’s domains • Plus hand searching the references • Yielded 173 articles • Applying inclusion/exclusion criteria resulted in 57 articles • From which 90 items were culled • Sorted into domains by modified Delphi technique Van De Camp, K., et al., How to conceptualize professionalism: a qualitative study. Med Teach, 2004. 26(8): p. 696-702. Expert group analysis

12. 3 domains • Interpersonal professionalism • Meeting demands for adequate contact with patients and other health professionals • Altruism, respect, integrity, service, honour,… • Public professionalism • Meeting society’s demands • Accountability, submission to an ethical code/moral commitment,… • Intrapersonal professionalism • Meeting the demands of the professional body • Lifelong learning, maturity, morality,…

13. The first step • Design a Q-sort based on the 90 items • Advantages of Q-sort • Fun and easy to perform • Computerised analysis package • Gives useable and meaningful numbers • Data rich • Disadvantage • Small sample size • But trade that off by using it to develop a questionnaire-type instrument Kerlinger, F.N., Foundations of Behavioural Research. 1986, New York: Holt, Rinehart and Winston Block, Jack (1961/1978): The Q-sort method in personality assessment and psychiatric research. Springfield, IL: Charles C. Thomas. (reprinted in 1978 by Consulting Psychologists Press, Palo Alto, CA).

14. Why Q-sorts ? • It forces people to make choices • And because the data is normally distributed, comparison between subjects is easier • And factor analysis is possible

15. Q-sort ordering (80 items) Pile 0 1 2 3 4 5 6 7 8 Cards 4 6 10 12 16 12 10 6 4 Agree Disagree Neutral

16. Data processing

17. Sayle and Taylor ASME 2006 • The five most favoured items describing professionalism, in order, were: • Good clinical judgement, • competence, • responsibility, • protect confidential information, • honesty

18. Next stages • We need a bigger “n” to have confidence over the factor analysis • Chronbach’s alpha is good, but then the number of items is high! • We need to see if 3rd year students differ from 1st or 5th years • We need to see if students differ from Doctors • It would be really interesting to see if Perry’s framework applies • and when they move from A to B – is C ever reached?! • Then we need to design an instrument using the critical domains.

19. Perry Type A 1.Basic Duality • Reality with no uncertainty or diversity, belief in absolute answers and authorities, obedience instead of responsibility. 2.Multiplicity pre-legitimate • Perception of diversity, but classified as unwarranted confusion. 3. Multiplicity sub-ordinate • Diversity and uncertainty accepted, but classified as temporary in a search for absolute answers. Clarkeburn, H.M., et al., Measuring Ethical Development in Life Sciences Students: a study using Perry's developmental model. Studies in Higher Education, 2003. 28(4): p. 443-456.

20. Perry Type B 4. Multiplicity correlate or First attempt to accommodate diversity and uncertainty • relativism subordinate with the expectation to do the right thing either by accepting no answers as truth-bearing or by subordinating to authority. 5.Relativism correlate, • Revolution through the inability to assimilate uncertainty competing, diffuse and the existence of absolute answers, everything becomes relativistic. 6. Commitment foreseen • Awareness of the need of orientation in a relativistic world, experimentation with different methods

21. Perry Type C 7. Initial commitment • Initial commitment in one area. 8. Orientation in implications of commitment • Experiences with commitment and responsibility, time of personal choices of how to fulfil perceived responsibility. 9. Developing commitment • Affirmation of identity among multiple responsibilities, commitment seen as an ongoing activity. There is an excellent inventory:Yang, F.-Y., Student views concerning evidence and the expert in reasoning a socio-scientific issue and personal epistemology. Educational Studies, 2005. 31(1): p. 65-84.