Journal Club

Wagner P, Hendrich J, Moseley G, Hudson V. Defining medical professionalism: a qualitative study. Medical Education. March 2007. 41 (3). p. 288-294.

Reviewed by Melissa Held, MD; University of Connecticut School of Medicine.

What is the problem and what is known about it so far?
There is no one agreed upon definition of medical professionalism and yet it is an important part of the core content of medical education. Many medical organizations such as the American Board of Internal Medicine have established "sets of professional responsibilities" to use as professional guidelines for physicians. The ABIM published "Medical professionalism in the new millennium: a physician charter" in 2002. This charter outlined professional responsibilities including a commitment to professional competence, honesty with patients, patient confidentiality, maintaining appropriate relations with patients, improving access to care, and others ¹. One criticism of the charter is that it does not take into account differing perspectives of learners at different stages of their careers or of patients.

What did the researchers do in this particular study?
This was a qualitative study which examined the findings of 8 focus groups who explored the meaning of medical professionalism. These groups consisted of medical faculty, residents, medical students and patients. Themes were identified and concept maps developed.

Who was studied?
Faculty and residents from the departments of family medicine and pediatrics at an academic medical institution, students rotating through their junior clerkship in family medicine, and active patients in an academic family medical center.

How was the studied done?
There were 8 focus groups comprising of 51 subjects (2 groups of each: faculty, residents, students and patients). Focus groups were led by 2 investigators using a set of trigger questions and a standard script of questions to encourage open-ended dialogue. Another investigator or research assistant took notes as a backup to audio taping. Audiotapes were transcribed. Data analysis was performed by an investigator experienced in qualitative analysis and data coding using immersion/crystallization. Investigators independently reviewed all transcripts and categorized items into themes. A theme table was generated. A visual concept map was then developed based on common themes among the groups with additional themes specific to groups. Consensus on themes and concept maps was reached via investigator discussion.

What did the researchers find?
Three primary and three secondary themes were common to all groups. Primary themes included knowledge/technical skills (being "competent" and "knowing your stuff"), patient relationships (trust and confidence) and character virtues (compassion, maturity, ability to show emotion, etc.). Secondary themes included medicine as a unique profession (handling intense issues, personal congruence, and peer relationships with a multi-disciplinary team).

There were unique themes by focus groups. Faculty focused on maturity and duty to patients (empowerment vs. authoritarianism). Residents discussed constant availability and duty to peers. Students were concerned about patient relationships ("didn't want to hurt anyone"). Patients also were verbal about relationships (asking about their comfort, voice tone, body language etc.).

What are the limitations of the study?
This study was conducted at a single institution using a small sample size. There are possible biases of the particular qualitative reviewers.

What are the implications of the study?
There are developmental shifts across learning stages in medicine. These differences should be explored further as they may contribute to the difficulty in finding a standard curriculum in teaching professionalism to medical students and residents.

Citations:

1. Medical Professionalism Project. Medical professionalism in the
   new millennium: a physician charter. Ann Intern Med. 2002; 136: 243-6.
   
   

Editorial Comment: It is interesting, but perhaps not surprising, that students, residents, and faculty had different ideas of what it means to be "professional". This may explain one of the difficulties in assessing professionalism in our trainees - perhaps we are assessing them on things that they do not see as important (which is why it is so important to have "anchors" on evaluation forms so that everyone knows what the standards are). This may also explain why when a student recently forged another student's signature for a mandatory teaching session, the students could not understand why our entire faculty team was appalled....Susan Bannister.