By Arsalan Manzoor Mughal1,2
- Department of Anatomy, Rawalpindi Medical College, Rawalpindi, Pakistan.
- Co-Director MHPE Program, Rawalpindi Medical University, Rawalpindi, Pakistan.
ORCID iD: 0000-0002-2757-7745
How to cite: Mughal AM. Professionalism – The Ignored Competence of Medical Education in Pakistan. Pak J Med Dent. 2022;11(3): 1-2. doi: 10.36283/PJMD11-3/001
Who is a good doctor? The answer is not that simple as professionalism in medical education is a complex concept with a lot of challenges for educators1. Professionalism is defined as “conduct, aims, or qualities that characterize or mark a profession”2. In medical practice, these skills incorporate clinical competence, communication skills, and ethical and legal understanding for the achievement of excellence, humanism, accountability, and altruism. In Pakistan, despite concern for the quality of skills and attitudes of medical graduates, the focus of corrective action is more on patient care and less on malpractice and professionalism. There are multiple reasons for unprofessional attitude in our graduates and doctors. There is a sense of superiority in doctors as the profession requires high merit, extensive time, and much more physical resources than other professions. That is why there is a high degree of dissatisfaction among doctors working for long hours, low salaries and inauspicious work environments. Coupled with no training in soft skills such as stress management they are more prone to exhibit unprofessional behavior. Inflexibility, the unacceptability of contrasting perspectives, ridiculing patients, substance use, unnecessary referrals to reduce workload and lack of teamwork, especially with paramedical staff are some of the behaviors commonly seen in our hospitals. Rectification of these problems is difficult because of the perception among doctors that social sciences such as professionalism and humanities are irrelevant to medicine and are simply common sense2.
All major competency frameworks in use today, both locally and internationally include professionalism, as an essential competency. For undergraduates, the Pakistan Medical and Dental (PM&DC) Document of 2011 mentioned professionalism as a competency with 100 hours allocated but did not describe any teaching and assessment methodology. The newer 2021 Pakistan Medical Commission (PMC) document has recommended professional teaching tools such as role-play, incidence reporting and reflective exercises to be used throughout the five-year program, reducing the recommended hours to 50 with no objectives and assessment tools. Similarly, for post-graduate programs, the College of Physicians and Surgeons Pakistan (CPSP) also lists professionalism in its competency framework. Workshops on soft skills are regularly conducted and are mandatory for trainees and supervisors, without assessment and monitoring of competency.
In the absence of a complete curricular framework, the following are the educational challenges for medical institutes in training professionalism in doctors:
The first is defining medical professionalism. As social, cultural, financial, legal educational and healthcare factors have a strong influence on the attributes of professionalism, it must be defined in context. Key professionalism themes defined by the Accreditation Council for Medical Education (ACGME) for residents are “Demonstrating professional conduct and accountability; Demonstrating humanism and cultural proficiency; Maintaining emotional, physical, and mental health; Pursuing continual personal and professional growth”3. In Pakistan, the common attributes of medical professionalism reported by the public, doctors and medical students include honesty, integrity, responsibility, reliability, sound judgment and maintaining confidentiality. The preferred attributes of undergraduate medical students have been reported to be excellence and altruism for public and private institutes respectively. Public sector faculty prefers the attributes of duty, honor, and respect; whereas, excellence is preferred by public sector faculty. Based on these findings, Pakistani medical institutes should develop definitions that should reflect their local context, be acceptable to stakeholders and aid in the development of interventional programs.
The second challenge is teaching and training professionals. Professionalism is considered part of the hidden curriculum, i.e., the curriculum which is not formally taught yet learned by the students. This is determined by the values of the institute and reflected by the ethos (credibility and ethics), pathos (emotions and feelings) and logos (logic and reasoning) of the administration and the workforce. These behaviors are acquired by the doctors from the organization’s prevalent culture. Interventions should be based on objectives that reflect the values and principles stated in the institute’s definition of professionalism and can be translated into observable and modifiable sets of behaviors. The focus of these interventions should be less on biomedical aspects and more on the moral development of students. Teaching should be in a structured experiential format as part of the declared curriculum4.
Lynne M. Kirk in her article has defined values of professionalism as Responsibility, Maturity, Communication Skills and Respect and aligned them with behaviors5. Workshops can be designed to modify these behaviors. Themes of such interventions can be Time management so that the candidates learn to arrive on time and follow up on tasks effectively thus demonstrating responsibility; Stress management so that one can accept blame for failure, not make inappropriate demands, not be abusive and demonstrate maturity; Communication skills to make one an effective listener and speaker; and Emotional Intelligence so that they are patient and sensitive to the physical and emotional needs of others.
Introduction to humanism in formal medical curricula is also essential in teaching medical professionalism. This should not be generic but tailored to cultural and societal needs. For undergraduate years, in addition to didactic lectures, students can be allotted families with a chronic illness that they can report back on. Small group discussions can be useful at this stage. For clinical years, role modeling and mentoring are recommended1.
The third challenge is an assessment of professionalism. In most of our universities and colleges where training on professionalism is conducted, there is no system of its assessment. It is recommended that assessment should be aligned to the levels of Miller’s pyramid i.e., Knows (specific and relevant ethical, legal knowledge), Knows How (Interpersonal, self-development, perceptions, and attitudes), Shows How (Interpersonal and self-development skills), Does (organizational and patient-reported outcomes). Tools for assessment can include written assessments for Knows, higher-order written assessments and assignments for Knows How, Observed Structured Clinical Examinations for Shows how, and 360-degree workplace-based assessments, supervisor reports and reflection portfolios for Does5.
The fourth challenge is the monitoring of professionalism. This can be done by developing policies for dealing with professional misconduct. These policies should be indigenous with clear reporting channels and shared with all stakeholders including students and staff. Unacceptable organizational behaviors should be investigated, and concerned individuals should be held accountable.
Universities and post-graduate medical institutes should rise to the challenge to define, teach, assess, and monitor professionalism with tools that are applicable and relevant to their local context. This will produce holistic doctors with a professional identity resulting in improvement in the teaching environment and patient care.
- Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Defining professionalism in medical education: a systematic review. Med Teach. 2014;36(1):47-61. doi: 10.3109/0142159X.2014.850154
- Jalil A, Mahmood QK, Fischer F. Young medical doctors’ perspectives on professionalism: a qualitative study conducted in public hospitals in Pakistan. BMC Health Serv Res. 2020;20(1):1-10. doi: 10.1186/s12913-020-05681-w
- Tay KT, Ng S, Hee JM, Chia EW, Vythilingam D, Ong YT, et al. Assessing professionalism in medicine–A scoping review of assessment tools from 1990 to 2018. J Med Educ Curric Dev. 2020;7:1-19. doi: 10.1177/2382120520955159
- Al-Eraky MM, Donkers J, Wajid G, van Merrienboer JJ. A Delphi study of medical professionalism in Arabian countries: The Four-Gates model. Med Teach. 2014;36(1):8-16. doi: 10.3109/0142159X.2014.886013
- Kirk LM. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007; 20(1):13-16. doi: 10.1080/08998280.2007.11928225
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