EDITORIAL | https://doi.org/10.5005/jp-journals-10082-02243 |
Development of Medical Professionalism: Curriculum Matters
1Department of Medical Education, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India
2Centre for Health Professions Education, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India
Corresponding Author: Balachandra V Adkoli, Department of Medical Education, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India, Phone: +91 9873029295, e-mail: balachandraa@mgmcri.ac.in
How to cite this article Adkoli BV, Parija SC. Development of Medical Professionalism: Curriculum Matters. J Basic Clin Appl Health Sci 2020;3(1):1–3.
Source of support: Nil
Conflict of interest: None
ABSTRACT
This article is second in the series of articles dedicated for the development of professionalism in medical education and practice. In the previous article, we defined the contours of medical professionalism, an area of greatest concern to the medical profession and the society alike. We also listed the attributes of a medical professional related to the four domains of functioning—patient care, teaching, research, and administration. In this article, we underline the importance of early sensitization and training of medical students, along with faculty development. We highlight the issues and challenges in designing a curriculum, including teaching and assessment of professionalism. We propose that the new competency-based curriculum recommended by the Medical Council of India is a good beginning, although much needs to be done to develop a comprehensive strategy for robust training and assessment of professionalism.
Keywords: Competency-based medical education, Medical education, Multi-source feedback, Portfolio, Professionalism, Undergraduate medical education.
INTRODUCTION
Medical profession, once most respected among all professions, has been under scathing attack by the public. Complaints against doctors are on the rise, while the job satisfaction among the young medical graduates is on the decline. In our previous article, we discussed the importance of professionalism and various issues that have mitigated professional behavior among the medical faculty, clinical practitioners, researchers, and administrators.1 The most important intervention to tackle this issue is perhaps the training of medical students based on a sound curriculum that lays solid foundation for future development of medical professionals.
The proverb “start early, drive slowly, and reach safely” is applicable for the development of professionalism. Professionalism should be inculcated at the early stages of medical training rather than taking punitive action against the doctors as and when they are proved guilty. This approach has three advantages. First, it prevents the doctors from the stigma attached by the society, which can jeopardize their career prospects. Second, research shows a high degree of correlation between those who were punished and derecognized by the professional bodies and those engaged in malpractice during while they were students.2 Third, professionalism, being a matter of attitude, is linked to “affective domain” that can be molded only during the formative, impressionable years of medical education. It is the right time to infuse professionalism in the mind of budding doctors. How to make this happen forms the main theme of this article.
Professionalism has been discussed at length worldwide.3,4 Teaching of professionalism is altogether different from teaching knowledge of signs and symptoms of a disease or skills in conducting physical examination, and prescribing treatment or follow-up, although it involves all these elements. The knowledge, skills, reflections, and communications should all be applied habitually and judiciously in an ethical manner to satisfy the needs of the patients.5 In fact, it is not merely the clients’ satisfaction but rather clients’ delight that we should expect and aspire in medical profession. However, it is not as simple as said. There are too many challenges to be addressed while we tackle the issue of teaching and assessing professionalism6 (Box 1).
Medical educationists around the world have debated the issue of introducing professionalism in medical education. Some even argue that professionalism is “caught” rather than “taught.” However, the consensus appears to be the need for a comprehensive strategy consisting of 4 main elements—(a) defining professional attributes or setting clear expectations of professional behavior; (b) role modeling and providing rich contextual experience in the class rooms, community, and service settings; (c) adopting a comprehensive evaluation; and (d) promoting a culture of professionalism.6
Response from the Indian Medical Education
Although medical education in India is more than 100 years old, we have hardly witnessed any serious attempt to teach professionalism in the medical curriculum.7 This is mainly due to three reasons. First, there are hardly any incidents of malpractices “reported” by the public. Second, regulations are already in place, although they have not been enforced strictly for various reasons! Third, our medical education system, during last few decades, has witnessed phenomenal growth in number of medical colleges, its enrollment, and development of new specialties that do not permit any breathing space for anyone to bell the cat!
Now that we are hearing about public outrage, quality enhancement, public accountability, patient safety, and satisfaction, it is right time to grapple with the issue of professionalism. A notable positive step in this direction has been the clarion call given by the National Medical Commission (NMC) that has replaced the Medical Council of India (MCI) in addressing this issue. Apart from defining the profile of an Indian Medical Graduate, the commission has mandated a competency-based medical education (CBME), which is in line with the global trend.8 It has also recommended introduction of a comprehensive module called Attitude, Ethics, and Communication (AETCOM). The salient features of AETCOM modules are highlighted in Box 2.
| Challenges in teaching |
| Professionalism, although rooted in technical competency, deals with humanistic aspects of medicine, such as effective communication, empathetic listening, caring, and compassion. It deals with the soft skills that are hard to teach! |
| There is no universally accepted list of professional behaviors to guide the teachers. However, the most commonly cited attributes are altruism, accountability, duty, honesty, integrity, passion for excellence, and respect for patients and colleagues. They are often context specific. |
| Professionalism is shaped by observing the behavior of seniors who act as “role models,” by way of “hidden curriculum.” It is also influenced by the attitudes and values that a student possesses including upbringing, early childhood experience, and influence of peers during schooling. The medical colleges have hardly any control over these factors. |
| Knowledge explosion has no bounds. While the curriculum is already overcrowded, it hardly gives any scope for adding any new element within the stipulated time. |
| Challenges in assessment |
| In absence of clear-cut definition of observed behavior, it becomes difficult to measure; many educators think that “without proper measurement, assessment cannot be done.” |
| The conventional tools of assessment such as MCQs, short-answer questions, long and short cases, and conventional viva exams are not suitable to assess the true behavior of students. |
| Authentic assessment of professionalism requires the students to be immersed in a real-life situation encountered in OPDs, wards, or communities. This is extremely difficult to achieve. The conventional settings of exam cannot capture the true essence of professional behavior. |
| AETCOM modules are based on Graduate Medical Education Regulations, 2017. The Indian Medical Graduate is expected to be a clinician, leader and member of health team, communicator, lifelong learner, and professional. In fact, professionalism touches each of these roles, directly or indirectly |
| A competency-based model has been applied. Under the heading of attitudes, ethics, and communication, 54 competencies have been identified, including 39 core competencies and 15 optional competencies |
| AETCOM has been designed as a continuum of learning experiences right from first year to final year of MBBS, using case scenario–based small group teaching. |
| There are 27 modules spread over a period of four professional years with 140 instructional hours allotted for study including self-directed learning. In each module, the competency is defined along with the expected level of five levels, namely, Knows, Knows How, Shows, Shows How, and Performs. This is in slight modification of Miller’s pyramid with four levels. |
| The methodology recommended in the AETCOM is “hybrid problem oriented approach” utilizing mostly case scenarios. The case scenarios are based on real-life or simulated cases that trigger thought process and discussion among students, facilitated by faculty in small groups or buzz sessions. |
| Each module involves a combination of lectures and extensive small group learning that facilitates problem-solving skills, collaborative learning, team work, reflection, and self-directed learning. |
| The AETCOM module outcomes are mostly assessed by formative assessment aided by maintenance of a logbook that captures continuous learning supervised and certified by the faculty as a part of competency-based approach. Summative evaluation has also been suggested in some cases in the form of a short-answer question. |
The AETCOM modules, if implemented in letter and spirit in all medical colleges, can definitely make a dent in the system. A well-laid foundation course at the beginning of MBBS, early clinical exposure, and a comprehensive stage-specific AETCOM module combined together in a competency-based framework are possibly the best possible package made available to the medical education system in the country in the recent times. The intention is good. However, its implementation depends on several factors, including preparedness of the teachers, in the backdrop of silo’s existing among various departments of a medical college.
While the efforts made by the MCI are laudable and commendable, we offer certain observations and suggestions for augmenting these measures. While competency-based approach is the much needed intervention, the higher education bodies such as UGC and the latter’s accreditation agency NAAC insist on “outcome-based approach.”9 Although the intention of both these bodies is the same, the terminology may cause confusion in the mind of educational institutes who are the implementers. It is therefore necessary for the regulators to come together with a consensus to clarify the terminologies before we embark upon curricular reforms. While CBME stresses the formative assessment, the final assessment rests with the examining agencies.
Set Clear Expectations and Define the Rules of the Game
Setting expectations of appropriate professional behavior is the foremost step because it helps in guiding the teachers in demonstrating right behavior and teach and assess students accordingly. The consequences of showing inappropriate behavior should also be made explicit and widely circulated. Within the framework suggested by the regulators, each medical college can appoint and empower the curriculum committee to oversee the implementation of curriculum in professionalism. The committee should come out with a concrete list of professional behaviors. Further, it should prepare protocols and SOPs for the smooth implementation of the guidelines. The procedures to deal with the students and teachers showing unacceptable behavior must be spelt out in clear terms. Some medical schools in the West appoint Progress and Promotions Committee to identify and reward those with exemplary professional behavior and recommend punitive action against the culprits in a timely and transparent manner.
Use Diverse Methods and Approaches in Teaching
There is growing consensus in favor of combined use of formal teaching and informal teaching supported by the influence of role models (hidden curriculum).
The AETCOM modules recommended by the MCI can greatly help in acquiring a cognitive base of professionalism. They can be supplemented by other modalities such as teaching of medical humanities, soft-skill training workshops, and community-based social service activities that give ample scope for students to engage in experiential learning.
Medical humanities are becoming increasingly important value additions, as they create space for handling overcrowded curriculum and tend to highlight the “human face” of medicine. The courses, workshops, interactive sessions, role-plays, theater. and movie activities such as theater of the oppressed can make a deep impact in changing attitudes. Only a few medical colleges have made some strides in this direction.10
The teaching of soft skills such as communication skills, caring and compassion can be supported by extensive use of digital media, video, and online resources, including rational use of social media.
The sites of learning must extend to OPDs, wards, and workplaces. In fact, most impactful learning of professional virtues can happen in a societal milieu such as community health centers, village health camps, disaster management camps, health melas, old age homes, dharmashalas, and orphanages. They can be organized in collaboration with nongovernment organizations who work passionately and become role models for the young medicos. Service learning holds the key for imbibing professional values.
Redesigning Approaches to Assessment
Assessment of professionalism is a complex issue because many of the attributes are not amenable for objective assessment using conventional tools such as written tests, MCQs, short, or long cases. Scenario-based written questions can be used effectively to assess the cognitive base.
We need to go for unconventional modalities of assessment which may be subjective but highly valid in assessing professionalism. The emphasis should be laid on the continuous feedback and reflection in the form of formative assessment, rather than summative assessment. Supplementing self-assessment with peer assessment, assessment by the nursing and technical staff, besides patient satisfaction surveys, can result in a robust system of assessment in the form of multisource feedback or 360° assessment that is becoming popular in the West. Analysis of narratives written by students, videotape analysis of student behavior, and “Professionalism Mini-Evaluation Exercise” are other useful tools that have been tried with success.
Portfolios and e-Portfolios Combined with Mentoring
Adoption of a learning portfolio combined with a mentoring system can become the backbone for continuous monitoring of professional growth. Portfolio approach consists of continuous documentation and reflection by the students, their day-to-day experience with patients. It can be a short description, a narrative, picture/photograph, PowerPoint, and audio/video-recording based on students’ experience with patients or peers. The supervisor examines the portfolio, interacts with the candidate and provides feedback. The information contained in the portfolio can be used for formative or even summative assessment. The e-portfolio can be a part of the learning management systems (LMS), which are becoming popular in progressive institutes. Even in many countries, the portfolio is a preferred method for showing evidence for fresh recruitment, promotion, or even grant awarding.
Some Final Thoughts
While curricular interventions such as the introduction of AETCOM Modules are promising initiatives, we need to augment faculty development for enabling and empowering faculty to carry forward this movement. Setting up a dedicated curriculum committee to clarify institutional expectations, training of the faculty in implementing AETCOM modules, augmenting learning experiences beyond class room, giving exposure to medical humanities, engaging students in service learning, and instituting a comprehensive evaluation can go a long way in enriching the curriculum toward development of professionalism. However, the curriculum is merely a vehicle for training. While the curriculum does matter, there are other issues beyond curriculum that ultimately decide the fate. This is what we term as “culture of professionalism” that we will address in subsequent articles.
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