Professionalism can be hard to define and even harder to teach. Dr Mark Dinwoodie, Head of Member Education at MPS, highlights some practical tips to encourage professionalism in trainees.
In the UK, doctors are good at reporting incidences of incompetence or unprofessionalism. A recent study showed that 73% of UK doctors who had knowledge of such incompetence reported it, compared to only 41% in Ireland.1 All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity are being compromised. Raising and Acting on Concerns About Patient Safety (2012) sets out the expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety.2 You may assume that it is patients who complain about you, but in reality it could be your colleagues who are disgruntled. There has been a year-on-year increase in the number and proportion (now 10%) of complaints received by the GMC about doctors from other doctors.3
What is professionalism?
The Royal College of Physicians defined professionalism in 2005 as a set of values, behaviours, and relationships that underpins the trust the public has in doctors.4
The concept of professionalism is the basis of medicine’s contract with society. It’s what society and patients expect of their healthcare professionals. Professionalism is the way that healthcare professionals fulfil their part of this contract and in return they are rewarded by the trust of patients.
How do you personify professionalism? Some people would see professionalism as being predominantly about observable behaviours. Others believe it is a much broader concept encompassing competences in terms of knowledge, clinical and non-clinical skills, which together with appropriate attitudes and values result in expected professional behaviours and relationships.
When it comes to day-to-day practice, professionalism is about adherence to a defined set of standards. You should work with your trainee to try and incorporate these standards and codes of practice into everyday behaviour and performance, by following the GMC’s guidance, Good Medical Practice.5
"When it comes to day-to-day practice, professionalism is about adherence to a defined set of standards"
A patient’s trust in a doctor is no longer assumed; it is reached and earned through a display of appropriate professional qualities and behaviours, for example, expertise, probity and concern or caring, and these act as markers of professionalism.
Communication issues and poor doctor-patient relationships are major causes of medicolegal action and complaints.6 Many of these communication behaviours would be viewed as unprofessional: poor communication (not being listened to, lack of empathy, lack of information), disempowerment (feeling devalued, not being understood or taken seriously), desertion (feeling abandoned, family excluded, staff arrogance).7
Trainers need to actively encourage professionalism and not just assume that trainees will automatically acquire it, or simply wait until they transgress. It’s relatively easy to teach someone a specific skill like injecting a shoulder and assessing whether the trainee has acquired the skill. The same can’t be said for professionalism. Teaching aspects of professionalism can be achieved through delivering a formal curriculum, teaching the knowledge and skills to develop capability, helping to establish necessary attitudes, and enabling our trainees to display appropriate professional behaviour.
Knowing the professional standards as identified by the GMC is a good starting point. Topic discussions with trainees are a useful way of teaching them about key issues such as confidentiality, consent, use of chaperones, etc. Ask them ‘how would you respond to a request for information from a patient’s relative?’ as a way to help them apply this knowledge.
Skills necessary to display professional behaviours
In order to be able to exhibit professional behaviour, we need to ensure trainees have the necessary skills which include clinical skills, a range of communication skills and record keeping.
Attitudes and values
Examples of attitudes and values associated with being a medical professional are: integrity, being open, compassion and accountability. To assess attitudes and values, you could ask attitudinal questions, for example: How much do you agree with the following statements (on a scale of 1-7): “It is important to apologise to patients when mistakes have occurred.” “It’s OK to take shortcuts if pressed for time.”
Is the behaviour attitude consistent?
Aligning attitudes and values with professional behaviours authenticates professionalism.
- Attitudes and Values (Humanism)
- Professional Behaviour (Professionalism)
What we see externally are behaviours and capability. It is what lies internally such as values, beliefs and attitudes that drive this behaviour. Professional behaviour without consistent underlying values lacks authenticity and integrity and is more likely to deteriorate when under pressure.
"Aligning attitudes and values with professional behaviours authenticates professionalism"
Informal and hidden curricula
Most of the teaching of professionalism is likely to occur through informal and hidden curricula. Role modelling can be very powerful especially if accompanied by reflection.
|Stories and anecdotes: “I had a case a few years ago where...”
||Developing an appropriate practice culture regarding attitudes and behaviours
|“Chats” over coffee
||Raising the profile of professionalism
|Medical and lay media “stories”
- • The way they see you act with patients
|Placements to help challenge attitudes
- • The way you act towards them
|Reflecting on and discussing everyday situations
- • The way you act to other team members
|Documenting examples of professionalism to discuss
- • The attitudes and values you express
Feedback on professional behaviour
You can assess the professional behaviour of trainees by roleplay, case-based discussion, rating scales and observation of a consultation. You can use formative assessment techniques to assess and enhance trainees’ capability.
"You can use formative assessment techniques to assess and enhance trainees’ capability"
Feedback from a variety of sources, for example, staff, patients or colleagues, can be very useful. We should be encouraging reflection, self-assessment and self-correction about the impact of errant professional behaviour.
Patient-centred v Doctor-centred
Being patient-centred is an important part of professionalism. Sometimes we can become very “me” focused and lose sight of the fact that the patient is our main priority.
Hearing these types of phrases may give an indication that this is happening:
“I don’t see why I should…”
“I had the usual time-wasters in this morning…”
“Patients need to realise that I can’t…”
Certain patient behaviours or comments can trigger an automatic inappropriate response which could be perceived as unprofessional, before our cognitive control has had a chance to prevent it. Identifying what these hot buttons are and early recognition that they are being pressed is important. Reframing patient behaviour that can stimulate these responses may help prevent automatic potentially unprofessional responses.
"Reframing patient behaviour that can stimulate these responses may help prevent automatic potentially unprofessional responses"
- Ensure trainees know and understands what acceptable professional behaviour is
- Encourage appropriate values and attitudes to authenticate professionalism
- Encourage patient-centred care
- Role modelling and facilitating reflection on observed behaviour is likely to be effective
- Enabling insight into attitudinal or behavioural deficiencies will help many trainees improve
- Reflective practice is vital to enable trainees to develop professionalism
- Reframing and managing hot buttons can be useful tools.
Professionalism matters. It’s what society and patients expect and helps avoid complaints and claims, particularly at a time when patient expectations are growing. In such times your professional attributes can really come to the fore and make all the difference when under pressure.
- Medical Council, Talking about Good Professional Practice (2014)
- GMC, The state of medical education and practice in the UK report: 2013
- Royal College of Physicians (RCP) Doctors in Society: Medical Professionalism in a Changing World p14 (2005)
- GMC, Good Medical Practice
- Beckman H et al, The doctor-patient relationship and malpractice: lessons from plaintiff depositions, Arch Intern Med 154(12):1365 (1994)
- Stephen F et al, A Study of Medical Negligence Claiming in Scotland, Scottish Government (2012).