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Journal of General Internal Medicine

, Volume 25, Issue 12, pp 1330–1336 | Cite as

Medical Professionalism: Conflicting Values for Tomorrow's Doctors

  • Erica Borgstrom
  • Simon Cohn
  • Stephen Barclay
Original Research

Abstract

Background

New values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation.

Objective

To investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum.

Methods

Qualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care.

Results

Professional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the ‘old’ model of professionalism that had not be directly taught to them. Integrating ‘new’ professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them.

Conclusions

The conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that ‘new’ models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.

KEY WORDS

medical professionalism medical education qualitative research students’ reflections 

Notes

Acknowledgements

The authors would like to thank the students who gave their consent for their portfolios to be in this study. We are grateful to the students and other colleagues who have provided feedback on previous drafts, including Diana F. Wood, John Benson, Thelma Quince and James Brimicombe. We further thank the James Knott Family Trust for funding this research, with additional funding from the General Practice and Primary Care Research Unit at the University of Cambridge.

Conflict of Interest

None disclosed.

Ethical Approval

The study was approved by the ethical committee of the University of Cambridge Psychology Research Ethics committee. All participants signed an informed consent form.

References

  1. 1.
    van Mook WNKA, de Grave WS, Wass V, O'Sullivan H, Zwaveling JH, Schuwirth LW, et al. Professionalism: evolution of the concept. Eur J Intern Med. 2009;20:e81–4.CrossRefPubMedGoogle Scholar
  2. 2.
    Southon G, Braithwaite J. The end of professionalism? Soc Sci Med. 1998;46:23–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Levenson R, Dewar S, Shepherd S. Understanding Doctors: Harnessing Professionalism. London: King's Fund; 2008.Google Scholar
  4. 4.
    Medical Professionalism Project. Medical professionalism in the new millennium: a physicians' charter. Lancet. 2002;359:520–2.CrossRefGoogle Scholar
  5. 5.
    Royal College of Physicians. Doctors in Society: Medical Professionalism in a Changing World. London: Royal College of Physicians; 2005.Google Scholar
  6. 6.
    American Board of Internal Medicine. Project Professionalism. Philadelphia, Pennsylvania: American Board of Internal Medicine; 1995.Google Scholar
  7. 7.
    Smith R. Medical professionalism: out with the old and in with the new. J R Soc Med. 2006;99:48–50.CrossRefPubMedGoogle Scholar
  8. 8.
    General Medical Council. Tomorrow's Doctors: Outcomes and Standards for Undergraduate Medical Education. GMC; 2009.Google Scholar
  9. 9.
    Stern DT, Papadakis M. The developing physician—becoming a professional. N Engl J Med. 2006;355:1794–9.CrossRefPubMedGoogle Scholar
  10. 10.
    van Mook WNKA, de Grave WS, van Luijk SJ, O'Sullivan H, Wass V, Schuwirth LW, et al. Training and learning professionalism in the medical school curriculum: current considerations. Eur J Intern Med. 2009;20:e96–100.CrossRefPubMedGoogle Scholar
  11. 11.
    Goldie J. Integrating professionalism teaching into undergraduate medical education in the UK setting. Med Teach. 2008;30:513–27.CrossRefPubMedGoogle Scholar
  12. 12.
    Rosen R, Dewar S. On Being a Doctor: Redefining Medical Professionalism for Better Patient Care. London: King's Fund; 2004.Google Scholar
  13. 13.
    van Mook WNKA, van Luijk SJ, O'Sullivan H, Wass V, Zwaveling JH, Schuwirth LW, et al. The concepts of professionalism and professional behaviour: conflicts in both definition and learning outcomes. Eur J Intern Med. 2009;20:e85–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Erde EL. Professionalism's facets: ambiguity, ambivalence, and nostalgia. J Med Philos. 2008;33:6–26.CrossRefPubMedGoogle Scholar
  15. 15.
    Jones L, Green J. Shifting discourses of professionalism: a case study of general practitioners in the United Kingdom. Sociol Health Illn. 2006;28:927–50.PubMedGoogle Scholar
  16. 16.
    Ginsburg S, Regehr G, Hatala R, McNaughton N, Frohna A, Hodges B, et al. Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med. 2000;75:S6–11.Google Scholar
  17. 17.
    Lief HI, Fox RC. Training for “detached concern” in medical students. In: Lief HI, Lief VF, Lief NR, eds. The Psychological Basis of Medical Practice. New York: Harper and Row; 1963:12–35.Google Scholar
  18. 18.
    MacLeod RD. On reflection: doctors learning to care for people who are dying. Soc Sci Med. 2001;52:1719–27.CrossRefPubMedGoogle Scholar
  19. 19.
    Halpern J. From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford Univ. Press; 2001.Google Scholar
  20. 20.
    Feest K, Forbes K. Today's Students, Tomorrow's Doctors: Reflections from the Wards. Oxon: Radcliffe Publishing Ltd.; 2007.Google Scholar
  21. 21.
    DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Acad Med. 2004;79:351–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Lane U. Revalidation: Project Initiation Document. 2009. Available at: www.gmc-uk.org/Project_Initiation_document.pdf_25397052 Accessed July 8, 2010.
  23. 23.
    Irvine D. The relationship between teaching professionalism and licensing and accrediting bodies. In: Cruess RL, Cruess SR, Steinert Y, eds. Teaching Medical Professionalism. Cambridge: Cambridge University Press; 2009:185–99.Google Scholar
  24. 24.
    Williams CM, Wilson CC, Olsen CH. Dying, death, and medical education: student voices. J Palliat Med. 2005;8:372–81.Google Scholar
  25. 25.
    Rosenbaum ME, Lobas J, Ferguson K. Using reflection activities to enhance teaching about end-of-life care. J Palliat Med. 2005;8:1186–95.Google Scholar
  26. 26.
    Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. Br Med J. 2004;329(7469):770–3.CrossRefGoogle Scholar
  27. 27.
    Merton R, Reader G, Kendall P. The Student-Physician: Introductory Studeies in the Sociology of Medical Education. Cambridge, MA: Harvard University Press; 1957.Google Scholar
  28. 28.
    Becker HS, Geer B, Hughes HC, Strauss AL. Boys in White: Student Culture in Medical School. New Brunswick: Transaction Publishers; 2007.Google Scholar
  29. 29.
    Sinclair S. Making Doctors. Oxford: Berg; 1997.Google Scholar
  30. 30.
    Helman C. The dissection room. In: Body Myths. London: Chatto and Windus; 1991:114-23Google Scholar
  31. 31.
    Good BJ. Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge: Cambridge University Press; 1994.Google Scholar
  32. 32.
    Bloom S. The medical school as a social organisation: the source of resistance to change. Med Educ. 1989;23:228–41.CrossRefPubMedGoogle Scholar
  33. 33.
    Brosnan C. Pierre Bourdieu and the theory of medical education: thinking ‘relationally’ about medical students and medical curricula. In: Brosnan C, Turner B, eds. Handbook of the Sociology of Medical Education. Oxon: Routledge; 2009.Google Scholar
  34. 34.
    Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Lock M, Gordon D, eds. Biomedicine Examined. Dordrecht, The Netherlands: Kluwer Academic Publishers; 1988.Google Scholar
  36. 36.
    MacKenzie CR. What would a good doctor do? Reflections on the ethics of medicine. HSS J. 2009;5:196–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Acad Med. 2003;78:802–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Block SD, Billings JA. Becoming a Physician: Learning from the Dying. New Engl J Med. 2005;353:1313–5.Google Scholar
  39. 39.
    Rabow MW, Wrubel J, Remen RN. Promise of professionalism: personal mission statements among a national cohort of medical students. Ann Fam Med. 2009;7(4):336–42.CrossRefPubMedGoogle Scholar
  40. 40.
    Fischer MA, Harrell HE, Haley H, Cifu AS, Alper E, Johnson KM, et al. Between two worlds: a multi-institutional qualitative analysis of students’ reflections on joining the medical profession. J Gen Intern Med. 2008;23:958–63.CrossRefPubMedGoogle Scholar
  41. 41.
    Howe A, Barrett A, Leinster S. How medical students demonstrate their professionalism when reflecting on experience. Med Educ. 2009;43:942–51.CrossRefPubMedGoogle Scholar
  42. 42.
    Branch WT. Small-group teaching emphasizing reflection can positively influence medical students' values. Acad Med. 2001;76:1171–2.CrossRefPubMedGoogle Scholar
  43. 43.
    Wear D. "Face-to-face with it": medical students' narratives about their end-of-life education. Acad Med 2002;77:271–7.Google Scholar
  44. 44.
    Hafferty FW. Into the Valley: Death and the Socialization of Medical Students. New Haven: Yale University; 1991.Google Scholar
  45. 45.
    Linde C. Working the Past—Narrative and Institutional Memory. New York: Oxford University Press; 2009.Google Scholar
  46. 46.
    Doyle D. Foreword. In: Randall F, Downie RS, eds. Palliative Care Ethics: A Good Companion. Oxford: Oxford University Press; 1996:vii–ix.Google Scholar
  47. 47.
    Lelonek M, Zink T. First code. Minn Med. 2007;90(8):31–2.PubMedGoogle Scholar
  48. 48.
    Brainard AH, Brislen HC. Learning professionalism: a view from the trenches. Acad Med. 2007;82:1010–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clinic Proceedings 2005;80:1613.Google Scholar
  50. 50.
    Caplan RP. Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. Br Med J. 1994;309:1261–3.Google Scholar
  51. 51.
    Van De Camp K, Vernooij-Dassen MJFJ, Grol RPTM, Bottema BJAM. How to conceptualize professionalism: a qualitative study. Med Teach. 2004;26:696–702.Google Scholar

Copyright information

© Society of General Internal Medicine 2010

Authors and Affiliations

  1. 1.General Practice and Primary Care Research UnitUniversity of CambridgeCambridgeUK

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