Medical Professionalism: A Series of Near-Peer Facilitated Workshops for First-Year Medical Students

Abstract

Introduction

Professionalism is a core competency of medical education. It impacts one's ability to generate rapport with patients, foster patient satisfaction, and enhance the overall well-being of the medical professional. Unprofessional attitudes among medical students have been associated with higher rates of career dissatisfaction and burnout. A group of faculty and medical students at our institution have developed a series of peer facilitated modules addressing a set of common themes relevant to medical professionalism: professionalism in the clinical setting, professional electronic communication, teamwork and community, and work-life integration.

Methods

Student discussions on professionalism were facilitated by senior medical students. Using a 5-point Likert scale, electronic pre- and postsurveys assessed the impact of the workshop on first-year medical students' understanding of various professionalism topics.

Results

Seventy-seven percent of first-year medical students (n = 131) felt the modules contributed to their learning. Pre- and postsurveys showed significant improvements in understanding of and comfort with the majority of topics discussed. Students felt that their knowledge improved as well. Narrative comments expressed approval of the modules and suggested they addressed unmet needs in the medical curriculum.

Discussion

These modules were successfully incorporated into the first-year medical school curriculum and led to improved student understanding and comfort around these topics. Senior medical student facilitators also found the experience useful in their own career development. Although these modules were designed for medical students, they may also be useful for other professional students (e.g., dental, nursing, etc.) or for interprofessional educational experiences.

Educational Objectives

By the end of Session 1, learners will be able to:

• 1.Explain the importance of confidentiality in the practice of medicine and discuss strategies to protect confidential information in a public setting.
• 2.Develop strategies to utilize when sharing information regarding previous clinical experience.
• 3.Discuss the importance of communicating tasks/responsibilities when they are unsure or feel they do not have the skills required to perform assigned tasks/responsibilities.
• 4.Demonstrate understanding of expectations about professional attire and use of downtime in the clinical setting.

By the end of Session 2, learners will be able to:

• 1.Discuss the role of evaluation processes in medical education and professional development.
• 2.Identify, as both medical students and health care professionals, best practices for sharing information on social media and use of email.
• 3.Explore the impact that unprofessional communications can have on relationships with patients and colleagues.

By the end of Session 3, learners will be able to:

• 1.Identify ways medical students can engage as productive members of a multidisciplinary care team.
• 2.Develop techniques for conflict management and consensus building.
• 3.Develop techniques for teamwork and collaboration.
• 4.Develop techniques for giving/receiving feedback.

By the end of Session 4, learners will be able to:

• 1.Discuss strategies for managing professional and personal expectations within the medical profession.
• 2.Reflect on how one's role within a health care team (e.g., patient, administrative staff, faculty, etc.) may impact individual expectations.
• 3.Explain how a shared understanding of team goals and tools for communicating concerns are linked to student development within the profession.

Introduction

Professionalism, a core competency of medical education, impacts patient satisfaction and plays an important role in generating rapport. Unprofessional attitudes among trainees are associated with higher rates of career dissatisfaction and burnout.¹ The first year of medical school is a time when students start to develop their identity as professionals and begin to grapple with the challenges this can entail. Many schools are integrating medical students into the clinical setting at earlier stages of their training, necessitating earlier integration of discussions surrounding professionalism.

In 2015, the University of Michigan Medical School adopted a new curriculum. In light of the curricular changes, some members of the student body expressed interest in developing learning modules to better prepare incoming students to address professional expectations and to guide their development. These students worked with faculty to create a student-driven professionalism curriculum. Topics for the modules were identified by group consensus and included content that was felt to be relevant, along with the addition of specific issues that had arisen as potential professionalism concerns in the past. The four general themes that were selected included (1) professionalism in the clinical setting (i.e., patient confidentiality, student appearance and proper attire, communication of trainee status), (2) professional electronic communication (i.e., email, social media, electronic feedback systems), (3) teamwork and community (i.e., participation in multidisciplinary care teams, conflict management, giving and receiving feedback), and (4) work-life integration (i.e., priority setting and professional expectations).

Because there are many nuances to appropriate professional conduct, we felt facilitated conversations would be more likely to foster free discussion and better understanding of behavioral expectations. Near-peer facilitators (more-senior medical students) have both cognitive and social congruence with beginning students, which may allow early learners to share their thoughts more freely than they would with faculty members.² Senior medical students were recruited to facilitate these small-group sessions, which were integrated throughout the year into a longitudinal doctoring course at the university. To prepare for the sessions, senior students participated in short pretraining meetings, as well as a debriefing meeting afterwards. These modules are appropriate for use in early professional training for physicians, dentists, physician assistants, and nurses, as there are no specific prerequisites for participation. Presenting them over the course of a year allows for integration of the concepts and for students to engage in additional experiences to inform their discussions.

Early integration of students in patient care is a cornerstone of our new curriculum; therefore, professional conduct in the clinical setting was selected as the focus of the initial session. Within this area, respect for patient privacy is foundational to developing the patient-physician relationship. Learning to engage in appropriate clinical discussions without violating this principle is an integral skill for the developing medical professional. Additionally, within one's role on a team, it is important to respectfully help other team members uphold these core concepts. With many levels of learners present in the clinical setting, it is also critical to communicate one's learner status accurately in order to facilitate entrustment decisions. Lastly, as patients can have expectations of medical professionals and these can be an area of misunderstanding for students, leading to problematic first impressions,³ we included guidelines for appropriate attire for medical professionals.

Professional use of electronic communication is a timely topic in medicine and is addressed in the second session. Social media posts by members and students of the medical profession, which are felt by many to be unprofessional, continue to be a concern.^4,4 Furthermore, examples of poorly conceived electronic communication between medical students and faculty in the form of emails, solicited electronic feedback, and quiz/exam commentary are remarkably common. Specifically, electronic faculty and course evaluations often include irrelevant information and fail to provide effective feedback to inform course and faculty improvement. Although students are well versed in electronic communication prior to matriculation, most do not have experience with its use in a purely professional setting. Moreover, as we are in the midst of a curricular change, student feedback on courses is especially critical for understanding the student experience. However, additional guidance was needed to aid in the development of these skills for professional use.

The delivery of health care in a team framework is becoming increasingly emphasized. Although leadership skills are important, students must also have the ability to recognize and assist peers who are struggling in order to optimize team performance. Burnout rates are increasing among health care providers and have been associated with an erosion of empathy in delivering patient care. Feeling supported in the clinical setting and believing that health care professionals have input into their environment have been shown to be protective,⁶ demonstrating the value of practicing these critical peer support skills at an early stage. This material is covered in the third session.

Although dialogue around the concept of work-life balance has grown in recent years, many in health care struggle to find true balance. Work-life integration is best achieved by learning how to prioritize competing demands and set appropriate boundaries. It is essential to develop a framework for assessing personal and professional commitments that can be adapted over the course of one's life and career. For early learners, these decisions can seem disconnected from patient care, and administrative rules can appear arbitrary. Differing and inefficient approaches to the work-life decision-making process have resulted in an increasing number of student requests for excused absences and postponements of required activities such as tests and written assignments. This in turn has led to misunderstandings and disagreements between students and faculty. Exploring this conflict through the medical professionalism curriculum provides an opportunity to frame these discussions around patient expectations and implications in the clinical setting.

There are currently no modules available on MedEdPORTAL to address the need for professionalism education of early medical students. To address topics related to student professionalism, we developed four 1-hour required workshops as part of the first-year curriculum, initially implemented in the 2015–16 academic year. Although these workshops were provided to first-year medical students (M1s), they would be useful for other professional students as well (e.g., dentistry, nursing, etc.).

The sessions center around discussion groups of 10–12 M1s paired with a third- or fourth-year medical student (M3/4) facilitator. They follow a case-based discussion format. Faculty are not allowed to sit in on these sessions to preserve the opportunities for open dialogue.

Methods

Four required, small-group, professionalism workshops take place throughout the M1 year. The content is selected using input from medical student and faculty leadership and review of the available literature. At our university, all M1s are required to participate in the workshops in small groups of 10–12 students. The sessions follow a case-based format with near-peer facilitation by an M3/4. The M3/4s are oriented to their role and the workshop's objectives 1 week prior via a 30-minute session. These 30-minute sessions review one of the four session topics (i.e., professional conduct in the clinic, including appearance, confidentiality, and communication of trainee status; electronic communication, including email, anonymous evaluations, and social media; teamwork and community; and work-life integration). While a few of the M3/4 facilitators have historically participated in more than one of the sessions, their clinical scheduling constraints limit these opportunities. Therefore, most sessions are led by a unique M3/4 when the group meets, thus demonstrating that each session can be presented as a self-contained module.

Target Audience

M1s are the target audience, although the cases could be easily modified for use with other professional students (e.g., dentistry, nursing, etc.).

Logistics

In our current curriculum, half of the M1 class meets for small-group doctoring sessions on 1 half-day each week. This workshop is included within this longitudinal small-group course and is provided at the end of the session so that faculty will not be present. The workshop material takes 1 to 2 hours to cover per session. Senior M3/4s are recruited in advance of the sessions and attend a 30-minute orientation session with student leadership the week prior to the workshop to go through the cases and discuss key learning points as well as strategies for small-group teaching. Using a 5-point Likert scale (1 = strongly disagree, 3 = neutral, 5 = strongly agree), electronic pre- and postsurveys assess the impact of the workshop on the M1s' understanding of various professionalism topics. This scale is presented in a multiple-choice format for ease of data collection. M3/4s are given the opportunity to meet as a group with coordinating faculty the week following the workshop to debrief on the sessions. Private small-group learning classrooms are needed for the sessions, but no other materials are necessary.

Module Outline and Materials

• •Session 1: Professional Conduct in Clinical Settings.
  • ○Appendix A: facilitator's guide for the M3/4s to help guide discussions, including key points to address during the session.
  • ○Appendix B: cases for student discussion.
  • ○Appendix C: pre- and postsurvey for assessing effectiveness of the session.
• •Session 2: Professional Use of Electronic Communication.
  • ○Appendix D: facilitator's guide.
  • ○Appendix E: cases for student discussion.
  • ○Appendix F: pre- and postsurvey.
• •Session 3: Teamwork and Community.
  • ○Appendix G: facilitator's guide.
  • ○Appendix H: cases for student discussion.
  • ○Appendix I: pre- and postsurvey.
• •Session 4: Work-Life Integration.
  • ○Appendix J: facilitator's guide.
  • ○Appendix K: cases for student discussion.
  • ○Appendix L: pre- and postsurvey.

Rationale Behind Case Formulations

The cases are intended to provide the opportunity for a meaningful discussion of themes within professionalism. As such, the cases have been intentionally designed to be without an obvious correct course of action, with the hope that this will generate meaningful discussion. We believe that an awareness of the conflicting priorities that often arise in these cases helps students make informed choices. The purpose of the questions found in the pre- and postsurveys is to help us gauge the effectiveness of this new curriculum. No credit is assigned to students based on their response.

Results

This workshop series was well received by both groups of medical students. Seventy-seven percent of M1s (n = 131) felt the sessions contributed to their learning. M3/4s who facilitated the course felt that this was a personally valuable experience, and they appreciated the opportunity to practice teaching skills prior to starting residency.

For each session, students completed a session-specific presurvey and postsurvey. Pre- and postsurvey response rates for the individual sessions ranged from 60% to 99%. Students felt the sessions improved both their understanding of and comfort level with most of the topics discussed. For example, comfort addressing a colleague who discusses confidential patient information in public increased from 2.77 to 3.18 when assessed using a 5-point Likert scale (p < .0001). Students felt their knowledge improved as well. When asked about consideration for how a reader may perceive anonymous comments and the impact on the effectiveness of the feedback, scores improved from 4.25 presession to 4.59 postsession (p < .001).

Regarding narrative feedback, one M1 stated, “These were great sessions and the ideas of professionalism were really important to share with my class, and to clarify what the expectations are for us as students training to be doctors.” Another student stated that

I appreciated the session where we discussed incidents of bias on the wards and how to handle those. It was one of the first times in medical school that I felt like we learned that it was important for us to speak up and advocate for our peers in these types of scenarios.

Discussion

These cases were created to help start a conversation with early learners in the health professions about what constitutes professionalism, with the hope that engaging in discussions about unprofessional behaviors might establish expectations for early learners and provide them with a framework with which to approach future conflicts surrounding professionalism. We chose these cases based on our experiences and on topics that both students and faculty felt were relevant and would stimulate robust discussion. These topics represent common concerns in medical professional behavior. Overall, the small-group sessions were well received. Comments from M1 learners stated that they felt they were able to get the real story about clinical experiences. They also explained that they experienced a greater depth of understanding and comfort with the topic and an increased appreciation for the guidance and insight shared by the senior students. In our experience, this was an early opportunity to facilitate conversations in these domains, communicate expectations, and allow learners to think about both their role in the clinical setting and their expectations as a member of a health care team. While it is too early to determine the impact of these sessions on outcomes such as reports of unprofessional activity or professionalism concern notes, the sessions have served as a platform for ongoing dialogue in our medical school community. Additionally, comparison of the pre- and postsurvey data shows significant changes in learner comfort in addressing areas that were discussed and in the role students see themselves playing as early learners on the team.

The evaluations for the sessions were initially performed manually with paper forms. As the sessions progressed, it became apparent that completing an electronic evaluation while students were still in the small group was important for maintaining high response rates. We did attempt a more global assessment of the sessions, with only 18 of 170 students responding. This limits our ability to draw strong conclusions about the professionalism curriculum outside of individual sessions. Additionally, since the Likert scale used a multiple-choice format, there is a potential for answers to be biased towards a correct response. Future iterations of this type of study may consider a traditional horizontal Likert scale.

Modifications over the course of the year included expansion of the initial facilitator's guides. The first three sessions included limited instructions to direct the small-group discussion, with the intent of not constraining the conversation. Feedback from senior students indicated that an expanded facilitator's guide, which included key concepts and examples they could consider for sharing their relevant clinical experience, would be beneficial. We incorporated this feedback in the development for the Session 4 facilitator's guide and subsequently revised the others for the upcoming academic year. Additionally, the order of the sessions has been altered as additional changes have developed within the curriculum, indicating sessions may be used independently or presented in a different order to fit an individual institution's needs.

Our initial plan was to recruit facilitators exclusively from the M4 class given its recent completion of core clinical rotations. Facilitating these sessions would provide an opportunity to expand the M4s' teaching portfolio and share their recent experiences. However, over the course of the year, limitations in scheduling such as recruitment/interview season, away rotations, and competing end-of-year events resulted in fewer M4s being available. Therefore, we expanded the role to include end-of-the-year M3s as well.

Other medical schools have expressed enthusiasm about implementing near-peer professionalism sessions with similar format and content. Although the four sessions presented here have been designed to address professionalism concerns at our particular institution, we feel these cases are universally relevant for training both medical students and other health care professionals. In addition, they may be used within interprofessional teams to facilitate conversation about team building, professional expectations, and the importance of honest communication in difficult situations. Future opportunities include ongoing monitoring of professionalism concerns that arise among learners and adaptation of the cases to reflect evolving challenges that students face during training.

Appendices

A. Session 1 Facilitator's Guide - Professionalism in the Clinical Setting.docx

B. Session 1 Cases.docx

C. Session 1 Pre- and Postsurvey.docx

D. Session 2 Facilitator's Guide - Professional Electronic Communication.docx

E. Session 2 Cases.docx

F. Session 2 Pre- and Postsurvey.docx

G. Session 3 Facilitator's Guide - Teamwork and Community.docx

H. Session 3 Cases.docx

I. Session 3 Pre- and Postsurvey.docx

J. Session 4 Facilitator's Guide - Work-Life Integration.docx

K. Session 4 Cases.docx

L. Session 4 Pre- and Postsurvey.docx

All appendices are peer reviewed as integral parts of the Original Publication.