This study explored the views of undergraduate medical students and teaching faculty at UK medical schools regarding what constitutes ‘adequate professionalism’ at different milestones of the undergraduate curriculum. BDs based upon regulatory guidance and tethered to waypoints along students’ journeys, enables detailed assessment of the emergence and maturation of medical student professionalism during their undergraduate career. The work establishes checkpoints for student progression throughout their undergraduate training. It also highlights varying teaching priorities at different curricular stages, and raises questions about both medical school admissions criteria and the expected standards for newly-graduated doctors.
UK medical regulator guidance(6) was used to define fitness-to-practise standards. This was considered most appropriate for a survey of UK-based medical educators and students. Postgraduate fitness-to-practise definitions were used since the purpose of undergraduate medical curricula is to produce graduates who can meet this standard. Alternative frameworks(7, 8) focusing specifically on undergraduate medical education could provide additional insights and future work will explore this subject. The milestones were designed to be appreciable across a range of curricular formats, recognising differences between medical schools.
The professionalism benchmarks provided by this study inform future curriculum design, and optimisation of which aspects of professionalism are taught at which stages of the undergraduate course. The data also supports the development of comprehensive professionalism assessment during students’ undergraduate careers. The detailed BDs focus on positive achievement and progression, rather than binary global assessment ratings or the avoidance of negative behaviours. This enables a roadmap to be created for individual students as their professional identities form and evolve(19). This speaks to several recommendations made by the Ottawa working group on professionalism assessment(20). For example recommendations 2 and 3 describe the need for “defensible assessment approaches across the continuum of professional development” and to develop “clearly articulated and operationalizable definition[s]” for this purpose.
The data was surprising in several regards. One might expect students to enter medical school as a novice in every regard, but this was not reflected in the results. Both student and faculty respondents felt that a more advanced level of proficiency was required in several areas at milestone A. These included English language skills, communication of student status and ability to maintain confidentiality. Some of these measures could be reflected in medical school admissions policies, but others may place unrealistic expectations on potential applicants. Further work should explore the potential influence of bias or prejudice on these expectations. It was also unexpected that achieving the ‘most proficient’ BD for each theme was not considered essential by graduation from medical school (milestone D). Even more surprising was that faculty held this view for 3 of the 15 themes, despite BD1 directly reflecting the regulatory definition of fitness-to-practise from the point of graduation. Further work should explore this unanticipated finding in more depth. Most surprising of all was the suggestion that slow progression through BD2 – concerning addressing patients’ basic needs – was satisfactory, and not essential to have mastered by graduation and entering the medical workforce. This may be at odds with the literature describing benefits of junior health care worker roles for medical students(21). It is feasible however that respondents were describing their perception of what currently happens rather than aspirations for what should happen. This might reflect an understanding of the complexity presented by this apparently simple theme, but patients and the public might disagree with this finding.
Student respondents had overall higher expectations than faculty respondents with respect to the BD requiring to be achieved across each milestone. This is perhaps unsurprising in the context of the literature describing medical students’ tendencies towards perfectionism. Being overly critical of one-self can lead to burnout in students(22). Attainment of many of the BDs described in this study traditionally reside in the hidden curriculum(2) and student expectations have not hitherto been explored in such detail. The insights provided here create opportunities for teaching faculty to openly discuss and rationalise expectations within their student cohorts, potentially reducing the risks of student distress and burnout.
Strengths and Limitations
The study utilised UK guidance for doctors to describe how professionalism is defined. It is well recognised that cultural factors, declinism(23) and differences between health professional roles can influence how professionalism is perceived by staff, patients and the public. Further work could replicate this study using an alternative regulator’s guidance as its basis. Similarly, further work is planned to explore the necessary amendments or additions to the BDs in light of Good Medical Practice(24) updates.
Small sample size and sampling bias are limitations of the study. Efforts were made to engage with every UK medical school, although only 8 schools provided responses. This did include a spread of newer and more established schools located across Scotland and England, but it is acknowledged that a broader response would have provided strength to the study findings. Similarly, relatively low proportions of the total student and faculty numbers in each school provided responses. The data was therefore amalgamated for analysis, limiting the ability to compare responses between schools. The data does allow the above observations to be made, however the potential sampling bias meant that formal statistical analysis of the data was not attempted. Further work to validate the conclusions drawn here would ideally gather data from more participants.
Respondents might not have been representative of their respective demographic groups. More broadly it remains to be seen whether medical students and teaching faculty can provide the most valid barometer of what constitutes ‘adequate professionalism’ during the undergraduate medical course. Future work should explore the views of patients, the public and other stakeholder groups.
The authors considered that each BD broadly represented typical student progression with respect to each theme. It is accepted however that these could benefit from further refinement with respect to some themes or milestones. For example, some schools might consider additional or alternative milestones to accommodate the needs of graduate entry programmes or where groups of students from external institutions join the course at the commencement of clinical training.
Acknowledging the above limitations, these data provide the first insights into how detailed assessments of professionalism might be performed during a medical student’s undergraduate journey. Crucially, the study provides detailed language and BDs that move beyond the existing tools relying upon global rating scales and binary measures. Further work includes embedding these BDs at the appropriate stages of medical school assessment and exploring whether student and faculty awareness of a student’s current status with respect to these BDs contributes positively to a student’s professional journey.