Context, Conflict, and Resolution

During medical school, students are taught the knowledge, skills, and attitudes required to become competent physicians. Knowledge and skills are rigorously evaluated by written and oral exams, standardized patient scenarios, and ward evaluations. However, evaluation of behaviors, including professionalism, is often implicit, unsystematic and, therefore, inadequate. This is problematic for several reasons. First, medical schools are doing a disservice to future postgraduate training programs, as well as to society, by not explicitly and accurately evaluating this area during medical school. It is recognized that more complaints against physicians to medical societies relate to unprofessional conduct than to lack of knowledge or poor technical skills.1 Yet students who display unprofessional behavior may not be identified in the current system, and will be promoted academically on the basis of adequate performance on tests of knowledge and skills alone.2,3 Second, we are doing a disservice to our students by not providing explicit feedback in this domain, thereby missing valuable opportunities to bring about awareness and improvement. The American Board of Internal Medicine, in its report “Project Professionalism,” discussed the problem of erosion of professionalism during medical training. While knowledge and skills improve markedly over the four years of medical school, there is ample anecdotal evidence, and substantial quantitative evidence, that professional behaviors can diminish over this period.4,5,6 There appears to be an unrealistic expectation that students will arrive at medical school lacking in knowledge and skills, but with a full complement of appropriate behaviors that require no further attention. However, all students are vulnerable to lapses in professional behavior and can benefit from explicit, systematic attention in this domain. The focus of medical education in the past century was on knowledge and skills. For the future of medicine, attention to the teaching and evaluation of professionalism is vital. While this need to evaluate professionalism effectively has been recognized for some time, traditional methods of addressing the problem have not been particularly successful, for several reasons. The traditional approach to this issue has involved the identification and definition of the attitudes and concepts that comprise the concept of professionalism (such as altruism, accountability, excellence, duty, honor, integrity, and respect). Evaluation methods that rely on such abstract and idealized definitions lead us to discuss people, rather than their behaviors, as being honest or dishonest, professional or unprofessional. This implies that professionalism represents a set of stable traits. Interestingly, a large literature exists that suggests the opposite. Many studies in personality psychology have shown that the presence of specific personality traits does not predict behavior.7,8. For example, in one study of psychiatry residents, Minnesota Multiphasic Personality Inventory testing revealed serious personality disorders in the two individuals who eventually lost their licenses for professional misconduct.7 However, several other participants showed the same personality traits, yet had no difficulty reported in 15 years of follow up. Thus, evidence suggests that the identification of specific traits does not allow us to predict an individual's behavior. There are several reasons why this issue is important when discussing the evaluation of professionalism. Stable trait measures do not take into account a recognition that behaviors enacted often involves an effort at resolving a conflict between two (or more) equally worthy professional or personal values. For example, it is easy to say that one must always tell the truth, and that one must always protect patient confidentiality. However, these values may occasionally come into conflict, and the ultimate choice the student makes will depend on the specifics of the situation.9,10 In addition, professional behaviors are known to be highly context-dependent.10,11 One can imagine a basically honest person lying to a patient given a particular context. This does not automatically mean that that person is dishonest, and therefore unprofessional. Certainly in social situations, a decision to always tell the full truth would be considered highly inappropriate. Although the issues of conflict and context are separate at a theoretical level, in day-to-day practice they are likely to interact. One study has shown that 87% of physicians surveyed indicated that deception is acceptable on rare occasions, for example, if the patient would be harmed by knowing the truth, in order to circumvent “ridiculous rules,” or to protect confidentiality.12 Yet, when two specific professional values are in conflict, it is not always predictable which of the two values will take precedence. For example, while it is sometimes appropriate to lie in order to protect patient confidentiality, there are circumstances in which it would be considered more appropriate to break confidentiality rather than tell a lie. As one participant stated, honesty is “usually” the best policy, but everything is taken on a case-by-case basis, and any actions taken depend on the specifics of the people and the situation.12 Traditional ways of evaluating professionalism do not make allowances for these gray areas. Another element of evaluating professionalism involves the process of resolving the conflict. The ultimate choice an individual makes, manifested as the behavior witnessed, does not tell us how he or she arrived at the decision. We know nothing of whether the student recognized the professional “values” that were in conflict, or why the student chose to act in that particular way. So while focusing on behaviors rather than personality or character traits is important, we must also attempt to understand the process that led to the behavior. Thus, if we do not include conflict, context, and the process of resolution in our evaluation methods, we might not be able to conduct the most reliable, valid, and appropriate evaluation of these behaviors. Another reason for the lack of success of traditional approaches is that evaluators have not been willing to identify an individual as unprofessional for actions that appear to be relatively minor. Thus, lapses in professional behavior tend to be ignored or suppressed, due to an understandable reluctance to apply the broad, harsh label of “unprofessional.”13 In one study, clinician supervisors admitted and demonstrated their reluctance to give negative feedback regarding unprofessional behavior, even though in interviews they had stated strongly that they would do so.14 Even if faculty have this willingness, they have been found to have “difficulty in identifying problems, an inability to verify problems, and fear of litigation” that inhibit their reporting of behavioral problems.2 This outcome arises, in part, from the fact that educators and researchers have traditionally focused on this problem from an abstract perspective. The definitions and subcategories of the broader concept of professionalism describe the idealized person, the “consummate professional,” with no room for mistakes. With this theoretical basis, if someone tells a lie, even for a “good” reason, he or she could be suddenly labeled “dishonest,” and therefore, “unprofessional.” The only thing left for the evaluator to decide, then, is how unprofessional the individual is. This top-down focus on professionalism as an abstraction rather than a bottom-up focus on professionalism as a set of actions in context, therefore, is flawed. This paper elaborates on the issues around this problem. First, we review the literature on the types of evaluation instruments used for measuring professionalism in medical education. We then outline fundamental conceptual deficiencies that exist in this literature. We argue that the three most important missing components are: consideration of the contexts in which unprofessional behaviors occur, the conflicts that lead to these lapses, and the reasons students make the choices they make. We then propose strategies for resolving these issues. Method We conducted searches through Medline, Psychlit, and ERIC for literature published over the past 20 years. We included studies that contained original research on the topic of assessment or evaluation of professionalism in medical education, or included instruments to measure professional behavior, professionalism, humanism, behaviors, values, and attitudes. After initial articles were identified, bibliographies were used to identify additional references, and experts in the field were consulted for missing but relevant papers. This process uncovered few studies addressing specific efforts to evaluate professionalism. There was an abundance of articles calling for new and better methods of evaluation, and arguments for why this is so important and neglected. Some papers dealt with certain aspects of professionalism, for example, ethics, communication skills, interpersonal skills, and humanistic behavior, but they did so without extrapolation to the larger notion of professionalism. These studies were included if they highlighted difficulties in evaluating professionalism or provided new insights or solutions, and contained original research. Results Evaluations by Faculty Supervisors. In 1979, the AAMC interviewed approximately 500 clerkship directors about “problem students.” They identified 21 types of problem students, and then asked how often each type of problem was seen, and how difficult the problem was. Among the results from the University of Washington School of Medicine, researchers found that “noncognitive” issues (e.g., bright but poor interpersonal skills) were “frequent and difficult,” but that the very disturbing ones (e.g., cannot be trusted, manipulative) were seen only infrequently.15 Though this survey was done many years ago, it provides an early glimpse of faculty's concerns about the professional behaviors of students. Since then, various other studies have analyzed approaches used by faculty in the evaluation of professionalism, including global rating scales, intraining evaluations, and encounter cards. Ward rating forms, completed by the physician-supervisor, are the most commonly used instruments. In addition to assessing medical knowledge and clinical skills, many of these forms have a single global item to assess professional behavior, which may be subject to extensive rater bias.16,17 A study by Woolliscroft et al. highlights some of the problems of using this type of assessment. The authors found that using a questionnaire, faculty could assess the humanistic qualities of internal medicine residents, at least for the item “doctor-patient relationships.”18 However, it would take 20–50 faculty members per resident to achieve acceptable reproducibility, which calls into question the utility of this instrument. This also suggests that the trait doctor-patient relationships is probably not stable, but rather may be subject to context bias. 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