Professionalism in teaching
In Achieving good medical practice, we say that students’ behaviour must justify the trust that patients and the public place on future members of the medical profession. We also say that we and medical schools will support students in their journey to becoming a doctor, including in the teaching and assessing of professionalism.
But how is professional behaviour taught at medical school? And what are the best ways to teach professionalism to medical students? We collaborated with The Point of Care Foundation, who produced 10 recommendations for how this could be done.
The Point of Care Foundation is a non-profit organisation which works to humanise healthcare for patients and the staff who care for them. The Point of Care Foundation trains and supports the people who facilitate the discussion in Schwartz Rounds.
These recommendations have been co-produced with medical students and teachers of professionalism. The Point of Care Foundation carried out research with all medical schools in the UK to inform the recommendations and determine how professionalism is currently taught. They also conducted qualitative interviews with medical students.
The co-production workshop highlighted a number of examples of good practice and a series of key principles, for the teaching of professionalism, which are summarised here as the Point of Care Foundation’s recommendations.
Make the over-riding message and ethos “You will make mistakes, and that’s normal.”
Medical schools can make this clear from the start. Students felt that doctors are on pedestals for the public and for the students; quote: “everyone is expected to be very special and then you suffer from ‘imposter syndrome’”.
“Then you discover [that doctors] have feet of clay and so do you: Have ‘human’ or fallible role models, teachers who will show that ‘good enough’ is OK”.
Students said that they gain coping strategies by talking to their peers and from clinicians who are brought in to talk about real life experiences, who have made mistakes and gone on to be successful, or perhaps changed aspects of their career. They want to hear from ‘real’ professionals, not archetypes.
Students said that Foundation schools should offer help to new graduates who make mistakes through educational supervisors.
Create a just culture, promoting learning not blame
“Medical schools need to say early on 'you will make mistakes and it’s OK'. We should be creating a culture where people can admit to mistakes without being blamed or laying blame.”
It is important for medical schools to:
- Create a psychologically safe space for sharing thoughts and experiences openly. This helps to promote insight into self and others as an iterative process.
- Promote candour and help people learn skills of candour. Personal experiences of interactions with patients and other situations students come across are key for learning about professional behaviour – especially where people went wrong and how they adjusted their behaviour for future.
- Discuss and tackle topical events openly, providing their students with as much information as possible to alleviate concerns.
- Introduce “what went well and even better if…”
Schwartz Rounds provide a structured forum where all staff, clinical and non-clinical, come together regularly to discuss the emotional and social aspects of working in healthcare. The purpose of Schwartz Rounds is to understand the challenges and rewards that are intrinsic to providing care, not to solve problems or to focus on the clinical aspects of patient care. The structure is a little like a medical Grand Round: a patient’s case may be presented (or a topic or event), but by two or three people from different professional backgrounds, and the emphasis will be on the impact that caring for the patient had on them. The discussion that follows will not be problem solving or judgmental but will be in order to explore non-clinical issues, and to reflect on the issues that the particular story raises for those who have listened to it. Research shows that the Rounds can help staff feel more supported in their jobs, allowing them the time and space to reflect on their roles. Evidence shows that staff who attend Rounds feel less stressed and isolated, with increased insight and appreciation for each other’s roles. Schwartz Rounds also help to reduce hierarchies between staff and to focus attention on relational aspects of care.
Schwartz Rounds are running in nearly 200 organisations in the UK and Ireland and have been introduced into medical schools, and in some universities. Rounds are run for a mix of medical, nursing and other students going into healthcare professions.
An evaluation of Rounds at UCL medical school showed that students were positive about Rounds and appreciated the chance to voice the psychological pressures of working in medicine:
“I think how you deal with your personal situation is something that’s really swept under the carpet in the medical profession”
“It helps knowing that whilst being professional you can still have feelings and get upset about things.”
It was also valuable to have senior doctors on the panel as role models:
“It was nice to see that someone so far into his career still has those heart-wrenching moments”.
Teach in small group settings
Teaching concepts around professionalism can be covered more effectively in a small group setting.
Good practice tips:
- The Gibbs reflective cycle (often used in nursing education) is useful, and emphasises the importance of recognising emotion.
- It is crucial to involve teachers and senior doctors and other health care professionals in this process.
- Role-modelling is important, and it’s good to have ‘flawed’ role models who can admit mistakes and difficulties.
- Have a framework for good feedback process. Teach how to give and receive 360 degree feedback, including from peers and patients.
- This could apply equally to teaching sessions in Foundation schools.
Example: Small group work (UCL)
As part of the UCL Clinical and Professional Practice module, there is small group work facilitated by individual tutors from a variety of healthcare professional backgrounds. One of the students who took part in the co-production workshop shares more details:
For one of the small group work sessions this year we were introduced to 360 degree appraisals. Prior to the session, all the second year medical students were emailed a link to an online feedback form which consisted of numerous statements followed by a rating scale and a comments box. This form required reflecting and feeding back on elements such as: how our peers communicate with patients, what their contribution and attendance to sessions was like, their ability to conduct clinical skills fluently and much more. We had to rate our own performance and (anonymously) the performance of the other members of our group.
During the session we were then given a summary sheet that outlined the score we gave ourselves next to the average score from our peers, along with any feedback comments. Thus the session focused on discussing how it felt to receive this feedback and whether it correlated to how we rated ourselves.
Although the process of rating 10-15 other students in the class was quite lengthy and there was an element of guilt if we rated each other too harshly, I think the introduction of the 360 degree appraisals at such an early stage was great. It was refreshing to see how your perception of yourself can differ from others, whether this was through underestimating or overestimating your abilities; the experience definitely grounds you and allows you to identify and appreciate both your strengths and weaknesses.
Furthermore, since the appraisals were done in an environment where there was tutor support and at a time when our learning was not affecting lives, it gave us the chance to learn how to become more open to receiving feedback without having to fear it. I think this sets us up well for our future as doctors. Regular sessions like this will enable us to adopt a habit where we will want to request regular feedback on our performance, so that we can always maintain a good standard of care for our patients.
Make teaching inter-professional
This can be done in a number of ways, starting with inter-professional teaching sessions.
- Expose students to teachers and tutors from backgrounds other than medicine as early as possible.
- Have inter-professional clinical teaching with other members of the healthcare team.
- Allocate personal/pastoral tutors from other disciplines, eg nursing.
- Bring other professionals into group work as part of the inter-professional environment, eg GPs, nurses, physiotherapists, hospital chaplains
- Bring patients in to the group.
Example: Students working Health Care Support Worker (HCSW) shifts (Southampton)
At the University of Southampton, second year medical students are required to work a minimum of four shifts throughout the year as a Health care support worker at an assigned ward. One of the key reasons for creating the scheme was that medical students felt relatively ‘lost’ on the wards, once they began their clinical attachments in the third year. One of the students who took part in the co-production workshop shares more details:
I was humbled to be given the opportunity to interact with patients in a clinical setting from an early stage of my medical career. I gained a true appreciation of what it means to deliver excellent patient centred care and the importance of having a cohesive team working together in delivering that care.
In retrospect, as I draw closer to the end of my time in medical school, I believe that all medical students should spend some time adopting or shadowing another role of the multidisciplinary team. Examples of this would be working as a HCSW or shadowing the ward clerk or nursing staff. Working with the various facets of the team will assist medical students as well as junior doctors to have a greater understanding of each person’s role and result in them integrating within the team more speedily.
Use different formats to teach and learn professionalism
- Accept different formats for teaching and learning about professionalism (eg podcasts, video, blogs, graphics, comics).
- Make it easy to learn in a variety of ways.
Use experiential approaches
Approaches which ground learning in ‘real life’ are important. An example is the patient shadowing programme:
Example: Alder Hey shadowing programme with medical students
Third year medical students at the University of Liverpool take part in the Improving Experience through Regular Shadowing Events (ImERSE) programme at Alder Hey hospital. This is a quality improvement programme which involves clinicians (in this case students) shadowing patients to gather information about how it feels to be cared for at the hospital, which can then be used to improve patients’ and families’ experience.
Students will stay with a child and family for a few hours and during that time use a standard template to record what they observe, how the patient spends their time, who they meet and their feelings at different times. They will also get the chance to understand a day case experience through shadowing a doctor, as they see the patient in the pre-op area for the operation and through until the doctor has spoken to the parents in recovery. They may watch more than one case as time allows and are asked to watch how the clinician builds rapport, takes consent and communicates with their colleagues in theatre. They are also asked to record two areas that contributed to a good experience for the patient and family, and are asked to reflect on what would have made it a better experience. They are asked to imagine whether they would have been happy with the experience if it had been them or a member of their family.
A student participating in the programme said:
Seeing how things are done from the point of view of the patient/family changed a lot of things. I put myself in their shoes, shared their anxiousness, nervousness, and finally the relief when he got out of surgery (since we can’t get in there). The nurses were kind but I would expect more care and words from the surgeon.
Assess professionalism within the curriculum
Medical schools can assess professionalism in a mixed format, and not thought of in the traditional manner of ‘pass’ and ‘fail’. It can be a balance between short written assessments (normally reflective writing) and face to face feedback and debate in small groups about aspects of professional behaviour.
Good practice tips:
- Some assessment is necessary to give ‘professionalism’ parity with other subjects.
- Don’t assess these topics in exams; assess them more informally and flexibly, using more formative ways.
- Use assessment and reflective portfolios, like learning logs.
- A non-judgmental environment is important.
- Count attendance to show the teaching of professionalism is taken seriously.
Teach professionalism at the right time in the curriculum
Good practice tips:
- Teach professionalism gradually. It can be helpful to start as quite directive and then open up to more difficult issues.
- Give professionalism parity with other parts of the curriculum and integrate it the teaching. Don’t separate it out but make it visible and acknowledge it.
- Spread professionalism through the terms/years.
- Teach professionalism and wellbeing throughout the curriculum.
- If you do assess professionalism via exams, don’t limit assessment into one exam.
Training on equality and diversity among patients and colleagues can improve relationships and understanding with each other, and promote professional behaviour.
Good practice tips:
- Add Unconscious Bias training to the curriculum.
- Encourage openness and willingness to ask and be asked about the different cultures of students and patients.
- Discuss diversity amongst colleagues as well as between professionals and patients.
Name unprofessionalism explicitly
Help students identify unprofessional behaviour and feel able to make a judgement about how to cope with it. Teachers and trainers in medical and foundation schools should be required to reflect on how they act as role models and should foster open discussion internally about what professional and unprofessional behaviours look like in practice.
The group that produced these recommendations agreed that if enacted together, they should also promote students’ wellbeing, but stand-alone wellbeing or resilience training was not advocated.