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Perceptions of Professionalism: Transformation across the Second and Third Years of Medical School


Medical students in hospital

Professionalism is often described as the social contract that doctors hold with society to ensure that they will always hold the interests of the patients above their own. Too often though, professionalism is presented in terms of actions or observable behaviors one must display rather than values one must hold. There is considerable debate among medical educators about teaching professionalism formally to medical students in school. Proponents point out a growing distrust of physicians in light of publicly aired breaches in professionalism conduct (e.g., malpractice and medical errors). Others contend professionalism cannot be taught and must be learned through experience. Indeed, medical students report learning how to act professionally (and how to not act professionally) by observing doctors interact with patients, medical students, and other members of the healthcare team. However, therein lies the problem: if professionalism is taught by observing doctors, what kind of professionalism are medical students learning if the doctor they are watching is acting unprofessional?

Numerous studies have examined how medical school influences students’ definitions of professionalism, including the formal professionalism lessons taught to students, interpersonal interactions with doctors, and other unstated, cultural influences of the institution. Some researchers have compared medical students understanding of professionalism at various stages of the four-year undergraduate medical education. However, these studies did not examine how individual views of professionalism evolve throughout medical school. This study presents a longitudinal analysis of how medical students perceptions of professionalism transformed across the second and third years of medical school and explored the aspects of the curriculum that were most influential during this time.

Nine medical students at IU School of Medicine shared their experiences with professionalism across the second and third years of medical school. The students participated in three interviews but also recorded 10 audio diaries where they reflected on their experiences and discussed how their experiences with professionalism were helping them to develop as future physicians.

Throughout the second and third years of medical school, the students reported their understanding of professionalism became more nuanced. In particular, as the students entered clinical rotations where they worked under doctors and began to interact more with patients and members of the healthcare team, their definitions of professionalism and their most valued aspects of professionalism began to slowly evolve.

In the second year, many of the students felt professionalism was used by the administration as a threat, or coercion tool, to make sure they were following the rules, presenting themselves professionally, and meeting certain expectations of conduct. For some students, this gave them a very narrow understanding of professionalism as a series of expectations of the individual, rather than situating professionalism in the context of healthcare, patients, and society. Experiences with faculty and the administration not meeting expectations then led many students to conclude professionalism was hierarchical, where those at the highest rungs were the ones least likely to exude professionalism.

As students entered the clerkships they were afforded numerous opportunities to observe professional and unprofessional behaviors by doctors. While in most experiences the doctors demonstrated utmost professionalism, those that did not served as exemplars of how not to act as a physician. Most students claimed they learned the most about professionalism through observations in the clinical setting and that they felt equipped to evaluate the professionalism of those they were observing. As a result, the students’ perceptions about professionalism gradually evolved from viewing professionalism as a mere collection of personal virtues to viewing professionalism as a duty to ensure that doctors are providing the best possible care for patients and the society they serve.

The views expressed in this content represent the perspective and opinions of the author and may or may not represent the position of Indiana University School of Medicine.

Jessica N. Byram, PhD

Assistant Professor

Jessica N. Byram received her Ph.D. in Anatomy & Cell Biology from Indiana University School of Medicine in 2017. She received her M.S. from University of Indianapolis in 2013 and her B.A. from Metropolitan State College of Denver in 2010. Her resear...