Through the modified Delphi, we were able to achieve consensus on the items for assessing medical professionalism. A consensual list of 23 items covering four domains of medical professionalism (Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills) was obtained from the two-rounds of Delphi survey. The domains of medical professionalism obtained from this Delphi survey were similar to other Asian studies. For Korea, the physicians deemed that “responsibility and duty”, “veracity, integrity, and honesty” and “rapport with patients and conversational skills” to be the most important sets of attributes of medical professionalism . For Chinese and Taiwanese stakeholders, seven common professional competencies were identified: clinical competence, communication, ethics, humanism, excellence, accountability and altruism .
In our study, 4 items “solicited feedback”, “advocated on behalf of a patient”, “extended his/herself to meet patient needs” and “used health resources appropriately” did not achieve the level of agreement to be included for both rounds, suggesting that these items may be less relevant in the local context as compared to other items in the list. This is largely in congruent with the findings of our previous qualitative study which showed that these items were less relevant to patients and/or faculty . Similarly, in a study to define professionalism in anaesthesiology, “resourcefulness” which is similar to “used health resources appropriately”, was deemed to be less important . This may be because of the difficulty to agree as to what is “appropriate use of health resources”, as raised by participants in this Delphi survey and in our previous qualitative study . Modifications to these items may be needed in the future after the pilot testing of the P-MEX.
In this Delphi survey, the two new items derived from the previous qualitative study- “communicated effectively with patient” and “demonstrated collegiality” both achieved the consensus to be included. This reflects the importance of effective communication and collaborative practice in medical professionalism locally, which is corroborated by the development and incorporation of various communication and interprofessional courses in local undergraduate and postgraduate medical education [38-41]. The emphasis on collegiality may also reflect the collectivist nature of Asian culture based on the Hofstede’s cultural dimension theory  and the increasing recognition that medical professionals practice in a community of practice .
Key strengths of this study include involvement of senior faculty, including the DIO and ADIO, who are involved in the disciplinary committees handling issues of lapses in professionalism in the residency programs. In addition, faculty from a range of disciplines (both surgical and medical specialties) participated in the Delphi survey and of different ethnicities. There was also no expert drop-out in the two rounds of Delphi survey.
Limitations of this study include the arbitrariness of the cut-off point utilised. The cut-off point of 70% adopted in our study was widely used in other studies [33, 34]. However, at this threshold, our findings should be taken as the best achievable consensus given the lack of robust evidence in this field rather than as evidence of absolute unanimity. In addition, the study may have selection bias as the experts were selected by the researchers. However, considerable care was taken during the study to select the experts based on their experience in handling of disciplinary issues in the residency programs, and to include faculty of various years of experience, gender, ethnicity and across various surgical and medical disciplines.