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Professionalism. David Taylor. Research question. What do medical students and Doctors understand by the term “professionalism”? This matters because medical students are expected to develop as professionals are tutor assessed Does their understanding change during their training?
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Professionalism David Taylor
Research question • What do medical students and Doctors understand by the term “professionalism”? • This matters because medical students • are expected to develop as professionals • are tutor assessed • Does their understanding change during their training? • Does Perry apply? • Dualism, relativism, comfort • Can we influence the rate of development? • Can we develop an inventory, or use an existing one? • Would peer assessment work?
What is known • Scribonius 47CE • The profession of medicine is defined as a commitment to compassion or clemency in the relief of suffering. • Pellegrino 2002 • A profession is a public statement of commitment • The doctor and the patient are in a covenantal relationship Pellegrino, E.D., Professionalism, profession and the virtues of the good physician. Mt Sinai J Med, 2002. 69(6): p. 378-84 Philosophical discourse
RCP Definition • Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors • Royal College of Physicians, Doctors in Society:Medical professionalism in a changing world. 2005, RCP: London. Interviews and expert group analysis
RCP Description • Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.
Doctors are committed to: • Integrity • Compassion • Altruism • Continuous improvement • Excellence • Working in partnership with members of the wider healthcare team.
Justice Potter Stewart • I know it when I see it. • obscenity
Attitudes and values Professional qualities Professional behaviour Professional habits Professional attitudes Professional demeanour Professional attributes/traits Personal qualities/personality Personal characteristics Psychosocial factors Hard to assess Non-cognitive factors Cohen 2001 • Cohen, R., Assessing professional behaviour and medical error.Med Teach, 2001. 23(2): p. 145-151. Cohen calls for direct observation of clinical performance – but what criteria?
Association for Surgical Education: Clinical Evaluation Protocols for Medical Students, 1985.
Larry Gruppen,(2005) Michigan Gauger, P.G., et al., Initial use of a novel instrument to measure professionalism in surgical residents. Am J Surg, 2005. 189(4): p. 479-87. expert group analysis
Van de Camp(2004) • Medline search using Cohen’s domains • Plus hand searching the references • Yielded 173 articles • Applying inclusion/exclusion criteria resulted in 57 articles • From which 90 items were culled • Sorted into domains by modified Delphi technique Van De Camp, K., et al., How to conceptualize professionalism: a qualitative study. Med Teach, 2004. 26(8): p. 696-702. Expert group analysis
3 domains • Interpersonal professionalism • Meeting demands for adequate contact with patients and other health professionals • Altruism, respect, integrity, service, honour,… • Public professionalism • Meeting society’s demands • Accountability, submission to an ethical code/moral commitment,… • Intrapersonal professionalism • Meeting the demands of the professional body • Lifelong learning, maturity, morality,…
The first step • Design a Q-sort based on the 90 items • Advantages of Q-sort • Fun and easy to perform • Computerised analysis package • Gives useable and meaningful numbers • Data rich • Disadvantage • Small sample size • But trade that off by using it to develop a questionnaire-type instrument Kerlinger, F.N., Foundations of Behavioural Research. 1986, New York: Holt, Rinehart and Winston Block, Jack (1961/1978): The Q-sort method in personality assessment and psychiatric research. Springfield, IL: Charles C. Thomas. (reprinted in 1978 by Consulting Psychologists Press, Palo Alto, CA).
Why Q-sorts ? • It forces people to make choices • And because the data is normally distributed, comparison between subjects is easier • And factor analysis is possible
Q-sort ordering (80 items) Pile 0 1 2 3 4 5 6 7 8 Cards 4 6 10 12 16 12 10 6 4 Agree Disagree Neutral
Sayle and Taylor ASME 2006 • The five most favoured items describing professionalism, in order, were: • Good clinical judgement, • competence, • responsibility, • protect confidential information, • honesty
Next stages • We need a bigger “n” to have confidence over the factor analysis • Chronbach’s alpha is good, but then the number of items is high! • We need to see if 3rd year students differ from 1st or 5th years • We need to see if students differ from Doctors • It would be really interesting to see if Perry’s framework applies • and when they move from A to B – is C ever reached?! • Then we need to design an instrument using the critical domains.
Perry Type A 1.Basic Duality • Reality with no uncertainty or diversity, belief in absolute answers and authorities, obedience instead of responsibility. 2.Multiplicity pre-legitimate • Perception of diversity, but classified as unwarranted confusion. 3. Multiplicity sub-ordinate • Diversity and uncertainty accepted, but classified as temporary in a search for absolute answers. Clarkeburn, H.M., et al., Measuring Ethical Development in Life Sciences Students: a study using Perry's developmental model. Studies in Higher Education, 2003. 28(4): p. 443-456.
Perry Type B 4. Multiplicity correlate or First attempt to accommodate diversity and uncertainty • relativism subordinate with the expectation to do the right thing either by accepting no answers as truth-bearing or by subordinating to authority. 5.Relativism correlate, • Revolution through the inability to assimilate uncertainty competing, diffuse and the existence of absolute answers, everything becomes relativistic. 6. Commitment foreseen • Awareness of the need of orientation in a relativistic world, experimentation with different methods
Perry Type C 7. Initial commitment • Initial commitment in one area. 8. Orientation in implications of commitment • Experiences with commitment and responsibility, time of personal choices of how to fulfil perceived responsibility. 9. Developing commitment • Affirmation of identity among multiple responsibilities, commitment seen as an ongoing activity. There is an excellent inventory:Yang, F.-Y., Student views concerning evidence and the expert in reasoning a socio-scientific issue and personal epistemology. Educational Studies, 2005. 31(1): p. 65-84.