Introduction

Professional behaviour in the medical educational context is currently a major issue.1 An ever increasing number of scientific publications pertaining to professionalism and professional behaviour has been written elaborating, for example, on professional behaviour from the perspective of societal expectations,2–3 patient safety,4 the definition of terms involved,5–8 teaching and learning,9–11 the development and use of different assessment methods,12–15 dealing with unprofessional behaviour,16–18 and legal implications.19

In line with this internationally shared urgency to describe and develop educational tools for teaching professional behaviour, all medical (8), dental (3) and veterinary (1) schools in the Netherlands have jointly invested in the development of a practical structure to optimise students’ learning and assessment of professional behaviour. The article presented herein describes the background and outcome of this combined effort (published in the Consilium Abeundi report: Projectteam Consilium Abeundi 2002 (Dutch version); Consilium Abeundi; English version).20–21 Limitations and hurdles in implementation will be discussed and future challenges will be touched upon.

Professional behaviour in Dutch undergraduate curricula

In the Netherlands, medical and veterinary studies last for six years; dental studies lasted for five years until 2009, and have now become six years too. Most of the students enter medical (dental, veterinary) school after finishing high school at the age of 18. Freshmen numbers are limited, by government order, ranging from about 80 (dental schools) to about 350 students per year (medical schools). A weighted lottery by the government in which grade point average scores of high school exams are decisive in who is admitted to the studies and who is not. From 2001 onwards, schools are permitted to select freshmen by themselves to a maximum of 50% of enrolment. Most Dutch medical schools now have a mainly preclinical (years 1–3) and a clinical (years 4–6) programme. The preclinical period is more theoretical; in the clinical programme students focus more on clinical experience. Elements of teaching and assessing professional behaviour have been introduced in the early nineties in some medical schools, expanding to all schools around 2000.

During medical school, a student is expected to perform according to appropriate medical norms and values. The student has to be prepared for internalising these values and norms during the curriculum. To achieve this goal, teachers and assessors scaffold by giving appropriate formative or summative feedback on students’ performance. This feedback is helpful for all students but, from the perspective of patient safety, is especially important for those students deviating from expected norms and values.

Before 2002, all medical, dental and veterinarian schools in the Netherlands had their own style and structure dealing with (un)professional behaviour by their students. This situation resulted in a wide variety of approaches, with schools ranging from hardly any explicit focus on professional behaviour, to other schools where evaluation forms were systematically used to examine students’ performance. At that time most schools had no administrative system to record incidents of serious unprofessional behaviour.

To facilitate a more uniform way to teach and assess professional behaviour, the Association of Universities in The Netherlands (VSNU) instituted a Special Interest Group on Professional Behaviour. Representatives of all Dutch medical, dental and veterinary faculties collaborated to this end. This group finalised a report on professional behaviour in medical undergraduate education in 2002 (Projectteam Consilium Abeundi 2002 (Dutch version); Van Luijk (2005) English version.20–21 This report included recommendations for teaching, assessment, coaching, and temporarily excluding students with unprofessional behaviour.

Defining professional behaviour

Professional behaviour is a term mainly used in a European setting, and seems to contrast with the term professionalism mainly used in the United States and Canada.22 While professional behaviour refers to observable behaviour, and includes a public centred view of professionals (outer shell)23–24, professionalism refers to values and norms of the profession (inner core). The latter comprises altruism, compassion, etc., and the relation of the profession with society.25–27

It is obvious that both approaches are two sides of the same coin. The Consilium Abeundi report provided a workable, practical description of professional behaviour. Basically, the description points to the fact that one should focus upon observable behaviour in which the standards and values of professional practice are demonstrated. For example, communication, behaviour, and appearance, all aimed at establishing the trust between the professional and the patient. The following dimensions of professional behaviour were distinguished: dealing with tasks or work, dealing with others and dealing with oneself.28

The recommendations

All the schools involved have agreed to adhere to the guidelines and recommendations formulated by the report. These recommendations focus on four categories: 1) general core elements with respect to professional behaviour, 2) recommendations about education and assessment, 3) recommendations about coaching students, 4) recommendations concerning legal status. More specific information concerning these recommendations is listed in Table 1.

The aim of this article is to describe the outcomes of the process to implement the guidelines, including hurdles encountered and challenges still to be met.

Method

Seven years after finishing the report the authors explored to what extent the recommendations had been implemented in spring 2009, a questionnaire was distributed by mail among the twelve participating schools to survey this. All schools’ representatives responsible for teaching and assessing professional behaviour in the curriculum were requested to address ten questions using an open answer format. This leaves the following questions to be discussed: 1) How is professional behaviour taught in the curriculum? 2) In which years and in which situations does behavioural assessment take place? 3) By whom is professional behaviour assessed? 4) Which instruments for assessment are used? 5) What happens in cases of a negative assessment? and 6) How is faculty trained in teaching and assessing professional behaviour?

Additional questions explored stimulating or inhibiting factors experienced in the implementation process of the recommendations. Participants were asked to formulate three stimulating and three inhibiting factors related to the implementation of the recommendations.

All twelve schools participated in the study. After the first round of information gathering, each school’s representative was given the opportunity, by direct mail contact, to adjust the categorisation results. All respondents approved the final results.

Table 1. Recommendations of the Projectteam Consilium Abeundi (Luijk SJ van (ed) Consilium Abeundi, 2005, English version).
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Table 2. Summary of the questionnaire results across all Dutch medical schools.
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Results

The results show that the goals of teaching and assessing professional behaviour as stated by medical (dental, veterinary) faculties are still fully endorsed by all schools.

Although discussions about assessment of professional behaviour are mostly focused on the poorly performing ‘unprofessional’ students, it must be stressed that all schools try to emphasise that assessing students’ performance is very beneficial for all students.

In general, all schools use similar teaching and assessment formats. These results are summarised in Table 2.

Data show that some aspects of teaching and assessment at the different schools can be improved. First, the role of the student in the assessment process is often marginal. Students are assessed by teachers but can, especially in small groups, also be invited to assess each other using peer assessment. This is hardly the case in most schools.

Subsequently, training students to assess professional behaviour is not common in all schools. This holds for teachers as well. Despite the fact that most teachers have had a general teacher training, only a few schools have teacher training courses specifically directed toward discussing and assessing professional behaviour.

Another aspect that arises from the data is that most schools have no overview of the number of students with unprofessional behaviour. This hinders defining the magnitude and content of the problem.

In addition to training, communication about teaching and assessing professional behaviour can also be improved in most faculties. Focussed information through booklets or internet about mission, vision, teaching activities, assessment of professional behaviour is sometimes not sufficiently available.

Although most schools focus on the same teaching methods and assessment procedures for professional behaviour, there is still a great variety in how and to what extent schools implement it. Some schools have already implemented a system that is integrated into many educational activities and discussions about professional behaviour have become more and more part of the ‘culture’, while others still try to get professional behaviour prominently on the agenda.

Several factors contribute to the implementation of professional behaviour in a curriculum. The results of our investigation into supporting and inhibiting factors for implementation are summarised in Table 3.

Discussion

The aim of the present survey was to evaluate the progress made in promoting teaching and assessment of professional behaviour in Dutch medical, dental, and veterinary education since the joined presentation of a report with recommendations in 2002. The following conclusions can be drawn by looking at the results of the questionnaire (Table 2) and comparing them with the original recommendations from 2002 (Table 1).

General core elements

With respect to the general core elements it can be said that every school focuses much more on matters concerning professional behaviour than was the case in 2002.

Teaching and assessment

With respect to teaching, there is a tendency to make professional behaviour more explicit and visible in the curriculum, rather than teaching new content. The introduction of professional behaviour as a defined concept has made students and faculty more aware of its importance and has given participants a ‘language’ in which to discuss behaviour with each other.

Table 3. Stimulating and inhibiting factors implementing recommendations for professional behaviour in medical, dental and veterinary Schools in the Netherlands.
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With respect to assessment, much more has been changed. Several committees of professional behaviour were installed to support the local examination boards in their task to organise assessment procedures and to give advice on how to handle unprofessional behaviour of students.

The rules and regulations in almost all schools consist of chapters about assessing professional behaviour and the consequences when students do not meet the criteria.

With regard to training faculty, much has been done but probably not enough. Teachers follow general teacher training sessions. However, sessions especially focused on professional behaviour are rare and should be offered more frequently. In doing so, teachers can be made more aware of the specific skills needed and can be trained in critical incidents when discussing elements of professional behaviour with a single student or a group of students. This will also enforce the implementation and contribute to changing the ‘culture’ when discussing each other’s performance in line with the research of Steinert.29–30

Students too should be involved in training, when we consider them as serious partners in discussing performance. For them it is as difficult as for teachers to give feedback to peers. Moreover, training them is part of their professional training because after graduation they are also expected to give feedback to unprofessional colleagues. Therefore training students to give feedback to their peers about professional behaviour is still a goal to be met. It stimulates reflective skills.31

Coaching of students with unprofessional behaviour

The recommendations stated that reflection upon one’s behaviour is a core skill that needs to be developed by students. There is definitely more attention paid to reflection skills in the Dutch curricula now.32 However, the impression still exists that there are too few opportunities for students to train and to develop reflection skills. Most schools use assignments to stimulate reflection, but students tend to dislike such assignments. Schools are still looking for other practical and evidence based teaching formats supporting reflective skills. Examination boards or committees of professional behaviour have almost no possibilities to help unprofessional students who lack self-reflection within a curriculum. This is a serious unsolved problem in training professional behaviour.

The recommendations favoured an exchange of case studies or examples of remedial teaching activities. This has been done during the past few years in several groups of student counsellors and also in the Netherlands Association for Medical Education – Special Interest Group on Professional Behaviour (NVMO). Despite these developments, it was not yet possible to construct a sound model for guiding students with unprofessional behaviour. Herein lies a clear challenge for the years to come. It is an extremely important issue and is also highly relevant for postgraduate education.

Legislation

Fortunately, Dutch law has changed per 1 September 2010, now making it possible to suspend students permanently from medical school in case of undisputed unprofessional behaviour.

General considerations

Implementation of professional behaviour in the curricula requires a process development in order to be successful. Awareness of the importance of the topic among faculty is crucial. Furthermore, leadership, organisational support and efficient assessment tools are crucial. If one of these elements lacks, the implementation stands on hold or is likely to fade out.

An important question is whether all efforts during the last years have led to better professional performance of students and therefore to a fewer number of reports of unprofessional behaviour. Unfortunately, this question cannot be answered yet. This is partly because most of the schools have little overview on the number of students with unprofessional behaviour and party due to more awareness among teachers and assessors and to clearer procedures on how to handle this problem. Therefore, it can be expected that more reports on unprofessional behaviour will appear in the years to come, instead of fewer, but probably not reflecting a higher incidence of unprofessional behaviour.

This study has its limitations. It was based on a questionnaire sent to all medical, dental, veterinary schools in the Netherlands. The authors collected and categorised the open ended questions, thus leaving room for some subjective interpretation developments reported. However, each participating school representative was given the opportunity, by direct mail contact, to correct misinterpretations. The results may therefore be considered representative for the Dutch situation.

Conclusions

It can be concluded that, following the recommendations in 2002, much has been done on teaching and assessing professional behaviour in the medical, dental and veterinary schools in the Netherlands. Most important for these developments are societal developments in which patient safety has become a major public issue. The recommendations have contributed to giving medical (dental, veterinary) schools a structure to respond to these societal developments.

Epilogue

After presentation of the 2002 report, the members of the task group continued to meet on a regular basis, between two to four times a year, with other professionals involved in teaching and assessing professional behaviour. This provided an – possibly unique – expert team to engage professionals representing all medical, dental and veterinarian schools in one country to further develop the implementation of professional behaviour in each school’s curriculum. This team is organised as the NVMO – Special Interest Group on Professional Behaviour.

Acknowledgements

The authors express their gratitude to all members of the Netherlands Association for Medical Education – Special Interest Group on Professional Behaviour – in medical, dental and veterinary education for their input for this paper.

Belangenconflict: geen gemeld

Financiële ondersteuning: geen gemeld

* Dit artikel verscheen eerder in Med Teach 2010;32(9):733–739.