How to encourage professionalism in your trainees

Professionalism can be hard to define and even harder to teach. Dr Mark Dinwoodie, Head of Member Education at MPS, highlights some practical tips to encourage professionalism in trainees

A recent study revealed that Irish doctors are far less likely to report cases of incompetence or unprofessionalism among colleagues. In fact, only 41% of doctors who had knowledge of such incompetence reported it, compared to 73% in the UK.

The report, Talking About Good Professional Practice,¹ which includes surveys of both doctors and patients, also suggests some patients’ trust is misplaced. While 77% of patients believe a doctor would tell them if a mistake had been made, just 63% of doctors completely agreed that they should disclose all significant medical errors.

The report underlines the continuing need to focus on defining and embedding appropriate values throughout doctors’ professional lives; it also highlights the need to build a workplace setting which enables doctors to put professional values into action. Collaboration with partners, including the Department of Health, HSE, independent hospitals, and postgraduate medical training bodies will be important to achieve this aim.

Minister of State for Primary Care Alex White said he would “encourage doctors not to be reticent” when they had knowledge of unprofessionalism. “It may be a culture has grown over the years where you don’t speak out and you don’t bring forward issues and gradually we have to change that, but it can’t be done by a simple edict.”²

What is professionalism?

The concept of professionalism is the basis of medicine’s contract with society. It’s what society and patients expect of their healthcare professionals. Professionalism is the way that healthcare professionals fulfil their part of this contract and in return they are rewarded by the trust of patients.

How do you personify professionalism? Some people would see professionalism as being predominantly about observable behaviours. Others believe it is a much broader concept encompassing competences in terms of knowledge, clinical and non-clinical skills, which together with appropriate attitudes and values result in expected professional behaviours and relationships.

The concept of professionalism is the basis of medicine’s contract with society

When it comes to day-to-day practice, professionalism is about adherence to a defined set of standards. You should work with your trainee to try and incorporate these standards and codes of practice into everyday behaviour and performance by following the Medical Council’s guidance, Guide to Professional Conduct and Ethics for Registered Medical Practitioners.³

A patient’s trust in a doctor is no longer assumed; it is reached and earned through a display of appropriate professional qualities and behaviours, for example, expertise, probity and concern or caring, and these act as markers of professionalism.

Communication issues and poor doctor–patient relationships are major causes of medicolegal action and complaints

Communication issues and poor doctor–patient relationships are major causes of medicolegal action and complaints.⁴ Many of these communication behaviours would be viewed as unprofessional: poor communication (not being listened to, lack of empathy, lack of information), disempowerment (feeling devalued, not being understood or taken seriously), desertion (feeling abandoned, family excluded, staff arrogance).⁵

Teaching professionalism

Trainers need to actively encourage professionalism and not just assume that trainees will automatically acquire it or simply wait until they transgress.

It’s relatively easy to teach someone a specific skill like injecting a shoulder and assessing whether the trainee has acquired the skill. The same can’t be said for professionalism.

Teaching aspects of professionalism can be achieved through delivering a formal curriculum, teaching the knowledge and skills to develop capability, helping to establish necessary attitudes, and enabling our trainees to display appropriate professional behaviour.

Knowledge

Knowing the professional standards as identified by the Medical Council is a good starting point. Topic discussions with trainees are a useful way of teaching them about key issues such as confidentiality, consent, use of chaperones, etc. Ask them “how would you respond to a request for information from a patient’s relative?” as a way to help them apply this knowledge.

Trainers need to actively encourage professionalism and not just assume that trainees will automatically acquire it or simply wait until they transgress

Skills necessary to display professional behaviours

In order to be able to exhibit professional behaviour, we need to ensure trainees have the necessary skills which include clinical skills, a range of communication skills, and record keeping.

Attitudes and values

Examples of attitudes and values associated with being a medical professional are: integrity, being open, compassion and accountability. To assess attitudes and values, you could ask attitudinal questions, for example:

How much do you agree with the following statement (on a scale of 1-7):

“It is important to apologise to patients when mistakes have occurred.”

Is the behaviour attitude consistent?

Aligning attitudes and values with professional behaviours authenticates professionalism.

What we see externally are behaviours and capability. It is what lies internally such as values, beliefs and attitudes that drive this behaviour. Professional behaviour without consistent underlying values lacks authenticity and integrity and is more likely to deteriorate when under pressure.

Informal and hidden curricula

Most of the teaching of professionalism is likely to occur through informal and hidden curricula. Role modelling can be very powerful especially if accompanied by reflection.

INFORMAL CURRICULUM	HIDDEN CURRICULUM
Stories and anecdotes: “I had a case a few years ago where...”	Developing an appropriate practice culture regarding attitudes and behaviours
“Chats” over coffee	Raising the profile of professionalism
Peer learning	Role modelling: The way they see you act with patients The way you act towards them The way you act to other team members The attitudes and values you express
Medical and lay media “stories”
Placements to help challenge attitudes
Reflecting on and discussing everyday situations
Documenting examples of professionalism to discuss

Feedback on professional behaviour

You can assess the professional behaviour of trainees by role-play, case-based discussion, rating scales and observation of a consultation. You can use formative assessment techniques to assess and enhance trainees’ capability.

Feedback from a variety of sources, for example, staff, patients or colleagues, can be very useful.

We should be encouraging reflection, self-assessment and self-correction about the impact of errant professional behaviour.

Patient-centred v doctor-centred

Being patient-centred is an important part of professionalism. Sometimes we can become very “me” focused and lose sight of the fact that the patient is our main priority.

Hearing these types of phrases may give an indication that this is happening:

“I don’t see why I should…”
“I had the usual time-wasters in this morning…”
“Patients need to realise that I can’t…”

Hot buttons

Certain patient behaviours or comments can trigger an automatic inappropriate response which could be perceived as unprofessional, before our cognitive control has had a chance to prevent it. Identifying what these hot buttons are and early recognition that they are being pressed is important. Reframing patient behaviour that can stimulate these responses may help prevent automatic, potentially unprofessional, responses.

Summary:

Ensure trainees know and understand what acceptable professional behaviour is
Encourage appropriate values and attitudes to authenticate professionalism
Encourage patient-centred care
Role modelling and facilitating reflection on observed behaviour is likely to be effective
Enabling insight into attitudinal or behavioural deficiencies will help many trainees improve
Reflective practice is vital to enable trainees to develop professionalism
Reframing and managing hot buttons can be useful tools.

Conclusion

Professionalism matters. It’s what society and patients expect and helps avoid complaints and claims, particularly at a time when patient expectations are growing. In such times your professional attributes can really come to the fore and make all the difference when under pressure.

Useful link:

Professionalism – An MPS Guide

References

Medical Council, Talking About Good Professional Practice
The Irish Times, Only half of doctors feel duty to report incompetence
Medical Council, Guide to Professional Conduct and Ethics for Registered Medical Practitioners, (7th Ed 2009)
Beckman H et al, The doctor-patient relationship and malpractice: lessons from plaintiff depositions, Arch Intern Med 154(12):1365 (1994)
Stephen F et al, A Study of Medical Negligence Claiming in Scotland (2012).

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