Fitting professionalism into

medical curricula

Charlotte Rees PhD, FRCP (Edin)

Faculty of Medicine, Nursing & Health Sciences

2

Talk overview

Medical students learn

professionalism though inter-related

aspects of curricula

How should educators best fit

professionalism into the medical

curriculum?

– What is professionalism?

– How should it be taught, learnt and

assessed?

– What are the tensions?

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What is professionalism?

No consensus definition of

professionalism

Understandings vary by

person, context and time

Definitions should be context-

specific (Monrouxe & Rees 2017)

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What is professionalism? (Monrouxe & Rees 2017, pp. 13-14)

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What is professionalism? (Medical Council of Hong Kong 2016, p. 8)

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What is professionalism? (Monrouxe et al. 2011; in press)

19 professionalism

dimensions in UK/AUS

medical students’ talk

13 Taiwan, 16 Sri Lanka

Dominant dimensions were:

– knowledge and patient-

centredness (TW)

– rules and individual attributes

(SL)

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What is professionalism? (Monrouxe et al. in press)

Knowledge: “we should have the medical

knowledge that we need… before we go to see

patients, that’s a basic” (TWY5F1)

Patient-centeredness: “You are doctors and

they believe in you so, what you can do is… just

[be with them]…” (TWY6F40)

Rules: “Maybe it’s not solely defined by our

profession, what our profession is, it’s rather on

the society... so their expectations should be the

standard of our professionalism” (TWY7M40)

Attributes of individual: “the way they [doctors]

behave… the way they move, [the] way they talk,

how they deal with people… all are included in…

professionalism” (SLY2M4)

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How should professionalism be taught and learnt? (Monrouxe & Rees 2017)

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How is professionalism taught through the formal curriculum? (Monrouxe & Rees 2017)

• Difficult to integrate professionalism into FC

as it crosses ‘departments’ (O’Sullivan et al. 2012)

• Different levels of integration across

schools

• Professionalism should take place in most

‘authentic’ context (O’Sullivan et al. 2012)

• Huge variation in methods with no

consensus about best practice (Birden et al. 2013)

• Personal reflections facilitated by faculty,

mentoring and role-modeling are most

effective (Birden et al. 2013)

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How is professionalism learnt through the informal curriculum? (Monrouxe & Rees 2017)

Students learn professionalism through role modeling

Role models are defined as: “people we can identify with,

who have the qualities we would like to have, and are in

positions we would like to reach” (Paice et al. 2002)

Role models are thought to possess clinical competence,

teaching skills and personal qualities

Learning from role models can occur through:

– Unconscious incorporation of observed behavior into practice

– Conscious reflection and attunement of emotion/values and then

adoption or resistance of observed behaviors (Cruess et al. 2008)

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How is professionalism learnt through the hidden curriculum? (Monrouxe & Rees 2017, p. 135)

Students can learn professionalism through attending to

aspects of hidden curricula (Gair & Mullins 2001; Hafferty 1998):

– The physical environment (e.g. value of discipline by quality of teaching space)

– The body (e.g. personal grooming and clothing of role models)

– Intentional socialization practices and resistance (e.g. recruitment

brochures/institutional mission statements)

– Institutional slang/humor (e.g. medical slang for patients)

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How should professionalism be assessed? (Monrouxe & Rees 2017)

Many argue for programmatic approach to assessment (Van Mook et al. 2009)

Assessment methods should depend on purpose and

characteristics (Sullivan & Arnold 209)

Some argue for professionalism assessment at

individual, interpersonal and institutional levels (Hodges et al.

2011)

Some argue for assessment at all levels of Miller’s

pyramid (Miller 1990; Hawkins et al. 2009)

Most professionalism assessment occurs at does/shows

how rather than knows how/knows levels

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How should professionalism be assessed? (Monrouxe & Rees 2017, p. 53)

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Tensions exist between what is

taught and what is learnt

Mixed messages create

professionalism dilemmas for

students (e.g. Monrouxe & Rees 2012)

Students commonly go along

with informal and hidden

curricula (e.g. Rees et al. 2013)

This can create moral distress

for learners (Monrouxe et al. 2015)

Curriculum tensions and professionalism dilemmas

15

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Pay more attention to informal

and hidden curricula, plus

enhance formal curriculum

Provide students with

opportunities to de-brief

Create open/safe fora for

students to share their

experiences in small groups (Christakis

& Feudtner 1993; Monrouxe et al. 2012)

Model sharing by discussing our

own professionalism dilemmas

As educators we need to:

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Professionalism needs to be

understood within its local context

Faculty need to think about the

impact of the IC/HC on

professionalism learning

Students experience

professionalism dilemmas within

workplace learning

We need to help them make

sense of these experiences as

part of FC

Key take home messages

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Research collaborators (e.g.

Prof Lynn Monrouxe, Dr

Madawa Chandratilake & Prof

Ming-Jung Ho)

Our research participants

Funders (e.g. British Academy,

ASME, AMEE, HEA, NES)

CUMEC colleagues for inviting

me to talk today

Acknowledgements

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Key reference for talk (http://au.wiley.com/WileyCDA/WileyTitle/productCd-1119044448.html)

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Birden H et al. (2013) Teaching professionalism in medical education: A best evidence medical

education (BEME) systematic review. BEME guide no. 25. Medical Teacher 35, e1252-e1266.

Christakis DA & Feudtner MA (1993) Ethics in a short white coat: the ethical dilemmas that medical

students confront. Academic Medicine 68, 249-254.

Cruess et al. (2008) Role modeling – making the most of a powerful teaching strategy. BMJ 336,

718-721.

Gair M & Mullins G (2001) Hiding in Plain Sight. In E. Margolis (ed.) The Hidden Curriculum in

Higher Education. New York: Routledge; pp. 21-41.

Hafferty FW (1998) Beyond curriculum reform: confronting medicine’s hidden curriculum.

Academic Medicine 73(4), 403-407.

Hawkins et al. (2009) Assessment of medical professionalism: who, what, when, where, how and

why? Medical Teacher 31, 348-361.

Hodges B et al. (2011) Assessment of professionalism: Recommendations from the Ottawa 2010

Conference. Medical Teacher 33, 354-363.

Medical Council of Hong Kong (2016) Code of Professional Conduct. For the Guidance of

Registered Medical Practitioners. Hong Kong: Medical Council of Hong Kong.

Miller GE (1990) The assessment of clinical skills/competence/performance. Academic Medicine

65(9), S63-67.

Monrouxe LV et al. (2011) Differences in medical students’ explicit discourses of professionalism:

acting, representing, becoming. Medical Education 45, 585-602.

References I

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Monrouxe LV & Rees (2012) “It’s just a clash of cultures”: emotional talk within medical students’

narratives of professionalism dilemmas. Advances in Health Sciences Education 17(5), 671-701.

Monrouxe LV et al. (in press) Taiwanese and Sri Lankan students’ dimensions and discourses of

professionalism. Medical Education.

Monrouxe LV et al. (2015) Professionalism dilemmas, moral distress and the healthcare student:

insights from two online UK-wide questionnaire studies. BMJ Open 5:e007518.

doi:10.1136/bmjopen-2014-007518.

Monrouxe LV & Rees CE (2017) Healthcare Professionalism: Improving practice through

reflections on workplace dilemmas. Oxford: Wiley-Blackwell.

O’Sullivan H et al. (2012) Integrating professionalism into the curriculum: AMEE Guide No. 61.

Medical Teacher 34, e64-e77.

Paice E et al. (2002) How important are role models in making good doctors? BMJ 325, 707-710.

Rees CE et al. (2013) Narrative, emotion, and action: Analysing ‘most memorable’ professionalism

dilemmas. Medical Education 47(1), 80-96.

Sullivan C & Arnold A (2009) Assessment and remediation in programs of teaching

professionalism. In: RL Cruess, SR Cruess & Y Steinert (Eds.) Teaching Medical Professionalism.

New York: Cambridge University Press; pp. 124-149.

Van Mook et al. (2009) Approaches to professional behavior assessment: Tools in the

professionalism toolbox. European Journal of Internal Medicine 20, e153-e157.

References II

Questions?