Department of Internal Medicine and Office of Educational Development
The University of Texas Medical Branch,
Galveston Texas

Abstract: This study was conducted to obtain a baseline understanding of the professional behavior of clinical faculty physicians from the medical students’ perspective. Students completed a professionalism evaluation of supervising faculty at the end of each required third-year clerkship over a one year period. Results were analyzed by specific behaviors and across clerkships. Differences were noted in the frequency of the types of problems seen, and varied by clerkship discipline. The most common transgressions of professional behavior reported were the use of derogatory language towards other services or patients and the disrespectful treatment of others. Our study served to provide objective feedback to the faculty about student perceptions of faculty as role models for professionalism while on clinical rotations.

Key Words: Professionalism, undergraduate medical education, role models

     Professional behavior is fundamental to the practice of medicine. To provide medical students exposure to the theories of professional behavior and clear practice guidelines, many institutions have introduced formal instruction and evaluation systems to track students’ professional development.^1,2,3 In addition to formalized professionalism education, a learning environment that reinforces optimal professional behavior is key to the internalization of these important concepts. Ideally, the theoretical concepts of professionalism are reinforced to students through the consistent observation of professional behavior among their teachers.

      As teachers, medical school faculty and volunteer physician preceptors accept the important responsibility of serving as role models to medical students.⁴ Prior studies have examined the characteristics that students and residents value in their teachers. Although a high standard of knowledge is vital, humanistic and professional characteristics are reported by trainees as important in role models.^5,6,7 We performed this study to better understand student perceptions of the professional behavior of the supervising faculty physicians at our institution. We hoped to gain insight into the culture our educational program, and to identify professionalism issues that might benefit from focused faculty development.

Methods

     A seven-statement “Evaluation of Professionalism” form was developed. Each statement began with “I observed my faculty…” and addressed issues that could be objectively assessed during standard student-faculty interactions (Table 1). Students responded to each statement on a four-point scale anchored by “consistently”, “frequently”, “occasionally”, and “never”.

     The form was shared with the seven third-year clerkship directors and agreement for clerkship participation was obtained. The Institutional Review Board reviewed the protocol and permission was granted to conduct the study. During the 1999-2000 academic year, the Evaluation of Professionalism forms were distributed at the end of each of the seven third-year clinical clerkships: Pediatrics (4 weeks), Internal Medicine (8 weeks), Psychiatry (6 weeks), Obstetrics and Gynecology (6 weeks), Family Medicine (4 weeks), Surgery (8 weeks), and the Multidisciplinary Ambulatory Clerkship (a combined Pediatrics, Internal Medicine and Family Medicine ambulatory rotation, 12 weeks). Students were asked to complete an evaluation form for each faculty with whom they had meaningful contact during the clerkship. Students completed the forms anonymously and were asked not to identity the faculty being evaluated. Students did identify the clerkship discipline, type of rotation (general vs. subspecialty) and location of the experience (on campus vs. off campus). A section for comments was provided.

     Responses were entered into an Excel spreadsheet and comments were transcribed. Comments that included faculty names were modified to remove all identifiers. The frequency of responses to each statement was tabulated. Graphic representations allowed a comparison of responses to each statement by clerkship. The data from each clerkship were further analyzed by rotation type and location. All comments were content analyzed for major themes and grouped for review.

      An additional analysis was performed by scoring each evaluation form using a simple rubric to obtain a binomial score. Specifically, if the student’s response to any of the statements was “consistently”, “frequently” or “occasionally”, the form was designated as “issues identified”. If the response to each of the seven statements was “never”, the evaluation form was designated as “no issues identified”. The percent of forms with “issues identified”(suggesting that the student observed some type of unprofessional behavior in the supervising faculty member), was compared to the percent of forms with “no issues identified” for each clerkship.

Results

      During the study period, 2,685 evaluation forms were collected from the class of 200 students. The percent of “never” responses are shown by statement and by clerkship (Table 2). There were notable differences in the reporting of problems of professional behavior by clerkship discipline, ranging from almost no problems reported (Clerkship D and E) to many problems noted (Clerkship G). [Note: Specific clerkship identities are deliberately not linked to the results of this report to avoid fueling speculation about disciplines or educational settings based on data from a single institution.] When the data were broken down further and analyzed by clerkship rotation and location, the frequency of reported problems was somewhat higher for general vs. subspecialty rotations and for on campus vs. off campus rotations. Our findings showed that the most common transgressions of faculty professional behavior reported by students were the use of derogatory commentary directed at other services, at patients, or toward a patient’s family.

      When viewing each evaluation form (e.g.: one student –faculty interaction) as a unit of measure, the frequency with which issues were noted varied by clerkship. Figure 1 shows the percent of evaluation forms, compared across clerkships, with “issues identified” vs. those with “no issues identified”.

     Students provided many comments about their supervising faculty. Many of the comments praised the faculty for providing excellent teaching and role modeling for the students. The majority of the negative comments dealt with issues of language use, inappropriate use of humor, disrespectful treatment of patients or colleagues, and apparent disinterest in teaching. Students also provided commentary regarding the professional behavior of other team members including residents and the nursing staff. These comments also tended to be at the extremes: either examples of exceptional behavior or comments revealing behaviors that had a negative impact on the learning environment.

Discussion

     This study served to provide a “snapshot” of the professionalism climate of our learning environment through the eyes of students. For this analysis, we limited our description of professionalism to behaviors that could be observed by students during standard student-faculty interactions. These behaviors reflect professionalism issues commonly addressed in the literature and those previously brought to our attention during discussions with students.⁸ Clerkship based focus groups, professionalism seminars and one-on-one discussions with students have supported our belief that observed actions and overheard comments have an important influence on medical students looking to first imitate, and then to duplicate, what they see and hear. The behaviors we selected for this study also have a potential to be modified with feedback, and therefore are valuable to recognize since change is possible.

     Because the data were collected throughout an academic year, students had an opportunity to complete the same evaluation form during each clinical clerkship. Differences seen in the responses to specific statements, and the overall differences in the evaluations between clerkships, suggest that the students did discriminate in their responses to each statement (see Table 2). Issues often discussed during the teaching of medical professionalism, such as breach of confidentiality and the inadequate disclosure of information to patients were faculty behaviors observed infrequently by students. However, unprofessional use of language and disrespectful behavior towards others were behaviors more commonly identified by students in faculty. Differences noted between clerkships are difficult to interpret. Potential explanations for these differences are many: a few unprofessional individuals in a department, a departmental attitude or belief unique to this institution, or even an attitude consistent across institutions in a specific discipline. Given that the primary focus of this study was to better understand student perceptions of the professional behavior and culture of our own institution, we are reluctant to over interpret or speculate more broadly on these finding.

     While these unprofessional behaviors by faculty members do not necessarily impact directly on the care of patients, they do influence the learning environment. Although our students have several early exposures to clinical care in the first two years of medical school, the emphasis of our medical curriculum in year three changes to full time clinical experiences. It is during the third year of medical school that students have their first prolonged exposure to clinical faculty in both a patient care and teaching role. Impressions of clinical faculty, and of specific specialties in medicine, are formed during this critical year of education. Role modeling experiences influence career selection at both the student and housestaff level.^9,10 Physician-teachers have an important responsibility to optimize the learning environment and to promote the professional development of the medical students through consistent, professional behavior. An environment with conflicting guidelines and practices can result in student behaviors that are contrary to professional expectations.^11,12

     Certain limitations of the study must be noted. The evaluation form was distributed at the end of each rotation along with other evaluation tools. Additional time for reflection, or focus group discussions of the clerkship experience, may have resulted in different frequencies of reported behaviors or more descriptive qualitative data, respectively Understanding a student’s reaction to a specific situation can also not be assessed by the methodology used. For example, a comment made by a faculty member about a patient may be considered derogatory by one student but not by another.

     While raising awareness of behaviors can be aided by studies such as this, changing the behavior of clinical faculty is much more challenging. Our findings have been shared with the Deans, Department Chairs and Clerkship Directors through a number of venues, and hard copies of the data were provided to these administrators with their own department’s data identified. The study results have been mentioned in presentations on professionalism including grand rounds and community-based faculty development workshops. It is hoped that understanding where change needs to occur will encourage some of the faculty members to recognize and modify their own behavior, and encourage others to work towards a culture where these behaviors are no longer tolerated among their colleagues.

      A follow up study on student perceptions of the residents is being completed. Additional plans are underway to study faculty of all four of the health care schools at our university

Acknowledgements

     The authors wish to thank Antoinette Hickerson for her assistance in the coordination of data collection.

References

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References

Szauter K, Williams B, Ainsworth MA, Callaway M, Bulik R, Camp MG. Student perceptions of professional behavior of faculty physicians. Med Educ Online [serial online] 2003;8:17. Available from http://www.med-ed-online.org.

Correspondence

Karen Szauter, MD
The University of Texas Medical Branch
Route 0420
Galveston, Texas 77555-0420