Professionalism and ethics: A proposed curriculum for undergraduates

Abstract

Professionalism is the attributes, behaviors, commitments, values, and goals that characterize a profession. In medical professional, it encompasses strong societal role and involves emotional component too. On the other hand, ethics is the study of morality – careful and systematic analysis of moral decisions and behaviors and practicing those decisions. Medical ethics focuses primarily on issues arising out of the practice of medicine. It is generally believed that professionalism and ethics are caught by watching your teachers and seniors and not taught formally. Professionalism and ethics are previously diffused passively to the students through “the hidden curriculum,” leaving a lot to chance. However, over the time, it has been advocated that graduates need to be formally trained in the concepts of professionalism and ethics. In this paper, we propose a formal curriculum on professionalism and ethics, tailor-made for Indian medical graduates.

INTRODUCTION

I was on a tour in a nearby country, when I got involved in a road traffic accident and was taken to a nearby hospital. I could not understand their language; all I could do was pray to my God that my doctor would be competent, caring, and trustworthy. I prayed that my doctor embodies professionalism and ethics.[1]

This simple scenario is enough to underline the importance of professionalism and ethics in medical practice. Professionalism remains vague for many because it bridges two seemingly unconnected quantities – the evidence-based rational science we learn and the emotional, psychosocial beings we touch. It has got naturally hardwired into our societal values that it goes undetected when we practice it but shows blaringly well when we fall short of it – and labeled as unprofessional. It is clear from the available literature that the mark of these unprofessional and unethical conducts shows up even as a medical student and that is where our intervention should start.[2]

In a case–control study, Papadakis et al. concluded that problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board.[3] This study showed that disciplined physicians were more likely to have concern/problem/extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15–4.02; P = 0.02). In another retrospective cohort study, Papadakis et al. concluded that poor performance on behavioral and cognitive measures during residency is associated with greater risk for state licensing board actions against practicing physicians at every point on a performance continuum.[4] It is pertinent to conclude that unprofessional behavior during graduation correlates with subsequent unprofessional behavior during practice, and thus, professionalism should be an essential competency that must be demonstrated for a student to graduate from medical school.

In general, professionalism can be summed up as “the attributes, behaviors, commitments, values, and goals that characterize a profession.” In the medical profession, it is slightly different because of its strong societal role and the emotional component involved. Simplifying it to its bare bones, professionalism is a habitual construct which includes key beliefs and virtues that will build the trust of the public on doctors. Going further, the American Board of Medical Specialties asserts that “medical professionalism is a (normative) belief system about how best to organize and deliver health care, which calls on group members to jointly declare (“profess”) what the public and individual patients can expect regarding shared competency standards and ethical values and to implement trustworthy means to ensure that all medical professionals live up to these promises.”[5] Professionalism competence is the “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.”[6] The definitions have been differing and evolving across space and over time. The more recent definitions are increasingly catered to include behavior that is easily observable and probably quantifiable too.[7] The attributes and behaviors of professionalism are accountability, altruism, commitment to excellence, compassion, integrity, respect, responsiveness, sensitivity to diversity, and sound ethics.[8]

Ethics is the study of morality – careful and systematic analysis of moral decisions and behaviors and practicing those decisions. Medical ethics focuses primarily on issues arising out of the practice of medicine. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. Ethics are also important in the conduct of medical research. Ethics has always been an essential component of medical practice. Ethical principles such as respect for persons, informed consent, and confidentiality are basic to the physician–patient relationship. However, the application of these principles in specific situations is often problematic since physicians, patients, their family members, and other healthcare personnel may not agree on “one right way” to act in a situation.[9]

REQUIREMENT OF AN EXPLICIT CURRICULUM

It is generally believed that professionalism and ethics are “caught,” and not “taught.” The medical student is generally taught the “right” treatment for the patient and not the “good” treatment. The “good” treatment is where we add patient’s values and preferences also into action.[10] Professionalism and ethics were previously diffused passively to the students through “the hidden curriculum.” In hidden curriculum, students learn by watching their teachers, but it leaves a lot to chance.[11]

The hidden curriculum as evident from daily happening has failed to impart these virtues into our medical graduates. The reason may be a phenomenon of universal mutation in human values, but when it manifests in this noble profession, it becomes very obvious. The other important factor to ponder is the amount of relativity in matters of ethical concerns. Therefore, it is important to explicitly put forward the core principles and also expand more on the attributes expected in a doctor. In this fast-paced world, where passive virtues get unrevealed or unnoticed, active teaching of principles of professionalism and the code of ethics are the need of the hour.[12] This is not to reduce the value of the hidden curriculum but to empower it.[7] Moreover, many a time, after becoming an integral part of medical profession, the enthusiasm or gaining further knowledge and skills goes down in physicians. A kind of stagnation develops. This not only hampers growth of the physician but also may prove catastrophic for the patients too. Hence, major focus of any curriculum on professionalism and ethics should be to develop the acumen of “lifelong learner” in the medical graduate, for his self-growth and growth of the society.

EFFORTS IN INDIA

Medical Council of India (MCI) in 2002 released its code of ethics which was a regulatory document on professional conduct, etiquette, and ethics of doctors.[13] In 2011, the vision 2015 document was released which promised a refreshing start by recommending integration of professionalism at various phases of medical education.[14] In a massive step, MCI, in its regulations on graduate medical education 2012, elaborated the roles of the Indian medical graduate (IMG) as a clinician, leader and member of the health care team, communicator, lifelong learner and with attributes of professionalism and ethics. The document highlighted the importance of competencies pertaining to professionalism and ethics and recommended it to be an integral part of the curriculum through a structured longitudinal and dedicated program for the same.[15]

Materializing on this, the MCI, earlier this year (2015), has released the Attitude and Communication (ATCOM) module to be implemented in the undergraduate curriculum after many years of planning.[16] This module is a well-structured curriculum to ensure uniformity and quality of this impending knowledge transfer across the country. This along with the upcoming competency-based curriculum planned by the MCI hopes to make the dream of the perfect IMG come true.

A PROPOSED COMPREHENSIVE CURRICULUM FOR INDIAN MEDICAL GRADUATES: THE ROAD AHEAD

Should it stop here? Defining professionalism and providing an elaborate curriculum will help in only sensitizing medical graduates but continuous assessment of this multidimensional construct is the best possible methods available to bring excellence in professionalism. Hence, a comprehensive curriculum including assessment for professionalism and ethics in medical graduates is the need of the hour. Here, we propose one such longitudinal curriculum, which will run throughout the undergraduate course, keeping regulatory bodies' guidelines in focus, as detailed further.

Goal

The goal is to develop a professionally sound IMG who thrives for excellence; is ethical; responsive and accountable to patients, community, and profession, by undergoing training through a longitudinal program stretched across full MBBS course in professionalism and ethics; and applies these principles of bioethics, professionalism, and law to provide effective medical care to the patient and responsible health care to the community.

Competencies

It will be reinforced that after training with this curriculum in place, the IMG should be competent to apply principles of ethics and professionalism in medical practice, in medical research, in professional communication, and in self-learning. In brief, the competencies expected from the IMG after having graduated through training in the proposed longitudinal curriculum of professionalism and ethics are outlined in Box 1.

Box 1.

Competencies in proposed longitudinal curriculum on professionalism and ethics

Learning objectives

For any curriculum to be successful, the learning and instructional objectives should be “SMART,” namely, “specific,” “measurable,” “achievable,” “relevant,” and “time-bound.”[17,18] It is very well said that “if you are not certain of where you are going, you may very well end up somewhere else and not even know it.”[19] Here, we are detailing specific, achievable, relevant, and measurable learning objectives, which will be time-bound as detailed in the content portion; pertaining to all three domains, i.e., knowledge, skills, and attitude for a comprehensive professionalism and ethics curriculum.

Knowledge

During initial years of undergraduate training in the 1^st and 2^nd year professional, stress will be given on the knowledge aspect more. Knowledge will be built up from understanding the various MCI documents and regulations to ethical codes, research guidelines, guidelines of good clinical practice, drugs and cosmetics acts, and consumer protection acts.[20,21,22,23,24,25,26] Various knowledge objectives are outlined in Box 2.

Box 2.

Learning objectives pertaining to knowledge domain

Skill and attitude

During final professional, starting from the late 2^nd professional itself, hands-on and practical training in dealing with ethical conflicts and dilemmas, communication skills, reaction time, and attitude during crisis will be imparted in pragmatic conditions. Various objectives pertaining to skill and attitude domain are listed in Box 3.

Box 3.

Learning objectives pertaining to skill and attitude domain

Course content (phase-wise distribution)

Time distribution

The total course will be of 160 h, spread across all phases of the undergraduate curriculum including Internship, as per the aspirations of the MCI. Ten hours from the foundation course will be used to lay the foundation of the concept of professionalism and ethics during that period while 12 h will be used as “Internship Orientation Program” for reinforcing the concepts at the start of the rotational internship postings. The outline of time distribution is depicted in Figure 1.

Figure 1.

Outline of time distribution across various phases of undergraduate training

Content proper

The content of curriculum for various phases is as outlined below:

Preclinical phase

Preclinical phase will include foundation course and MBBS 1^st professional phase. Content will include:

• History and various regulations (22 h)

  • Hippocratic oath and other more modern oaths taken by physicians and its significance; literary discussion on history of medicine, core values, and the aim of medicine (3 h)

  • MCI Regulations for Undergraduate Medical Education 1997 and 2012, MCI Professional conduct, Etiquette, and Ethics Regulations 2002, Overview of MBBS program (4 h)

  • Introduction to medical research and ethics in medical research; Ethics in biomedical research; ICMR guidelines 2006 (4 h)

  • Ethics in research involving animals; CPCSEA guidelines (1 h)

  • Medical, legal, and ethical issues related to drugs (alcohol, narcotics, etc.) (3 h)

  • Introduction to legal aspects of donating body after death (1 h)

  • Consumer protection act relevant to medical practice; doctors' indemnity insurance; rights of patients and doctors, and associated duties and responsibilities (6 h)

• Core concepts (23 h)

  • Definition, concepts, and principles of professionalism and ethics; value and dignity of human life (5 h)

  • Roles of a physician and professional attributes/qualities; situations where application of professionalism and ethics is needed; application of professionalism and ethics to nurture professional relationships with different stakeholders (12 h)

  • Introduction to communication skills for interacting with colleagues, paramedics, patients, and relatives, etc., (5 h)

  • Conflicts of interest: Definition, types, and principles for identifying them (1 h).

Paraclinical phase

• Core concepts (20 h)

  • Principles of ethics and professionalism–medical ethics in patient care, research, and publication (5 h)
  • Concept of human rights; laws (civil and criminal) and its role in medical practice including significance of informed consent and record keeping (10 h)
  • Patients' and physician’s rights, consumer protection act, and informed and written consent (5 h)

• Communication skills (15 h)

  • Communication and counseling – history taking, examination of patient and patient education, soft skills of communication (15 h).

Clinical phase

The clinical phase will consist of final proof and internship period. Content proper will include as follows:

• Core concepts (38 h)

  • Professionalism: Nine domains, i.e., honesty and integrity; accountability; responsibility; respectful and nonjudgmental behavior; compassion and empathy; skillful communication; confidentiality and privacy in all patient affairs; self-directed learning; and appraisal skills (10 h)
  • Ethics: Principles of ethics; Nuremberg code and Helsinki declaration; informed consent (parts/elements/how to administer); ethics of research (5 h); medicolegal and ethical situations (6 h); ethics and patients autonomy (5 h); medical negligence (7 h); dealing with death (5 h)

• Situational management (10 h)

  • Building of concepts for professional and ethical management in various tricky situations such as assisted suicide, codes of ethics, confidentiality, conflict of interest, conscientious objection, empirical ethics, ethical dilemma, ethical principles, ethics of care, euthanasia, fiduciary, Hippocratic ethos, justice, morality, and privacy; patient-based medicine (10 h).

• Communication and interpersonal relationships (20 h)

  • Principles of communications: How to communicate diagnosis, prognosis, and treatment (10 h)
  • Doctor–patient relationship (5 h)
  • Relationship of a doctor with machines and medicines (5 h)

• Internship orientation program (12 h):

  • Reinforcing concepts of professionalism and ethics (6 h)
  • Time management (1 h)
  • Stress management (2 h)
  • Leadership and working as a team (3 h).

Course contents may appear as repetitive at certain places, but the level of competencies achieved in those course contents and objectives will be different in different phases and will progress sequentially from “know” to “know how” to “show how” across different phases longitudinally

Teaching learning tools

Teaching learning (TL) tools for imparting module of professionalism and ethics have to be innovative and nonconventional as imparting merely theoretical knowledge is not going to fill the gap between expectations and current actual scenario. It is not possible for an individual to imbibe soft skills such as attitude, empathy, and ethics by polishing the rote memory. Moreover, the chosen TL tool will depend on the phase of undergraduate training and feasibility issues. Initially, during preclinical and paraclinical phase, a method imparting more knowledge so as to address the “knows” and “knows how” areas will be more feasible and practical option; while during clinical phase, the chosen tool should be the one which can focus on “shows how” area. The various TL tools recommended for training in professionalism and ethics module are as follows.

Interactive lectures and large-group discussion

It will be appropriate to have interactive lectures and large-group discussion initially during the preclinical and paraclinical phase so as to have a sound knowledge base and have more clarity about the concepts, expectations, and gaps. Subsequently, in the late paraclinical phase, the focus can be shifted toward small-group discussion.

Case-based learning, case scenarios, and case studies

With the start of the clinical phase training, case-based scenarios can be introduced which can address soft skills such as patients' confidentiality, patients' autonomy, interaction with patients and their attendant, maintenance of composure in the face of grave emergency, and breaking bad news. Small-group teaching will an ideal tool at this stage, leading to reflective writing and brainstorming.[27] Bedside teaching and simulated patients can be some of the other methods of teaching professionalism and ethics.

Self-directed learning, reflective writing, and brainstorming

During clinical phase and rotational internship period, undergraduate students should be encouraged to reflect on their interactions with the patients.[28] After small-group teaching, brainstorming will encourage more and more students to share experiences and reflect. Prior distribution of handouts followed by self-directed learning, followed by case scenarios, followed by reflections and brainstorming will be a perfect platform to learn.

Video cases/clips and cinemeducation

Alexander et al. coined the term, “cinemeducation” to explain the approach of using commercial film clips to teach psychosocial medicine.[29] Medical educationalists have found films to be a useful teaching tool with their larger than life vivid portrayals.[29] Video clips anchor students' insights about patients from clinical practice and illustrate family life cycle issues. Movies capture learners' attention, expose them to diverse lifestyles, engage the humanistic side of physicians, and imprint powerful pictorial images in memory. Teaching with film clips is time efficient and provides emotionally engaging experiences for faculty and students. Video slips have been used very efficiently in social sciences and psychiatric illness, for giving the students and residents an insight into the patients' condition and disease.[29,30,31] In the same way, video clips of relevant portions of the movies can be used to train students in the aspects of humanity, empathy, communication skills, ethics, conflict management, and professional dilemmas and can give a long-lasting impression in the mind of the students.

Role modeling

The conventional phrase that professionalism is caught holds good to some extent even today. Students are bound to copy the ATCOM skills of their teachers and seniors, knowingly or unknowingly. Hence, teachers should be encouraged and sensitized to conduct themselves as role models all the same time.[32]

Other TL methods can be field visits as community worker, panel discussion, debates, and conduct of skits. Portfolio can be used during rotational internship posting.

Assessment methods

As we know assessment drives learning, regular assessment will be conducted for this module too. Assessment will primarily be subjective and mostly formative.

Formative/internal assessment

Various tools which can be used will depend on:

1. MBBS phase under consideration

2. Competency level being assessed

3. Feasibility issues.

During the initial phase of MBBS training, when more of knowledge pertaining to “knows” and “knows how” areas are to be assessed, multiple-choice and short answer questions will form the majority of the assessment tool. As the level of competencies goes higher, focus will be shifted to multisource feedback and directly observed behavior.

Directly observed behaviors or may be the videography of patient encounters of the students will be ideal platform for providing formative and instant feedback to the students and for making efforts to ensure any amend in the behavior.

Professional mini-assessment tool is a structured observation tool and consists of 21 items. Each item is rated on a 4-point scale of unacceptable, below expectations, met expectations, and exceeded expectations. In addition, any behavior showing clear breach of professional boundaries can also be documented on the observation sheet. At the end of the exercise, the assessment is discussed with the trainee and formative feedback is ensured.[33]

Patient satisfaction reports and portfolios can be utilized during internship period. During internship, assessment should be continuous and should be made an integral part of internship training, evaluation, and certification.

Efforts should be made to club more than one objective for each tool and conversely, more than one tool for each objective should be used. The various assessment tools recommended for formative assessment of professionalism and ethics are outlined in Box 4.[34]

Box 4.

Assessment tools for formative assessment of professionalism and ethics

Summative assessment

Tools can be used for summative assessment of the module too, and it is recommended that some portions of final summative assessment of clinical specialties should ensure to cover this module of professionalism and ethics.

For assessment of knowledge competencies

At least one question in each paper of the clinical specialties in the university examination should test knowledge competencies acquired during the professional development program.

For assessment of skill competencies

Skill competencies acquired during the professional development program must be tested during the final university clinical, practical, and viva. As during internship training, students will have more encounters with patients, and as they will actually perform under supervision in pragmatic conditions, professionalism and ethics should be marked as qualifying competency for certification of successful internship completion.

CONCLUSION

Professionalism and ethics are a construct and should neither be introduced in isolation from other medical graduation course contents nor be assessed so. It should be coherently assimilated with the current curriculum, and the competencies should be developed alongside other competencies and skills required from a medical graduate. Sufficient time is available within the currently adopted curriculum to spare for professionalism and ethics module.

With the course content, objectives, competencies, TL tools and assessment tools having been outlined in this document, it is presumed that medical colleges in India under the guidance of the regulatory body will find it much easier to introduce and implement professionalism and ethics module in declared curriculum, and we will encounter more professional physicians who are ethically strong.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.