|Year : 2020 | Volume
| Issue : 2 | Page : 230-234
Perspectives about professionalism among undergraduate students in a medical college in India: A qualitative study
Prasad Tukaram Dhikale1, Saurabh RamBihariLal Shrivastava2, Srikanth Srinivasan3
1 Department of Community Medicine, Hinduhridaysamrat Balasaheb Thackrey Medical College and Dr. R N Cooper Hospital, Mumbai, Maharashtra, India
2 Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth – Deemed to be University, Ammapettai, Nellikuppam, Chengalpet District, Tamil Nadu, India
3 Department of Community Medicine and Family Medicine, AIIMS, Jodhpur, Rajasthan, India
|Date of Submission||05-Jun-2019|
|Date of Acceptance||27-Mar-2020|
|Date of Web Publication||2-Jun-2020|
Dr. Saurabh RamBihariLal Shrivastava
Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (SBV) – Deemed to be University, Tiruporur - Guduvancherry Main Road, Ammapettai, Nellikuppam, Chengalpet District, Tamil Nadu - 603 108
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Professionalism has been recognized as an important competency of a doctor by various regulatory bodies. Objectives: The purpose of the study was to explore the perceptions of medical undergraduate students and to assess their attitude on professionalism. Materials and Methods: It was a qualitative study in which four focus group discussions were conducted, one for each year of course. Results: A total of seven themes emerged after the qualitative analysis of the data, namely qualities of a good doctor, need of teaching professionalism, ways of learning professionalism by medical students, ways of teaching professionalism, assessment of professionalism, factors promoting professionalism, and factors hindering professionalism. The students perceived that a good doctor should be committed to excellence, responsive and accountable to patients, profession and community, selfless, healthy, good communicator, ethical and law abiding, practice integrity, and social justice. The students preferred to learn professionalism by role modeling by faculties and case-based scenario discussions. Conclusion: Medical undergraduate students should be briefed about the need and importance of professionalism through small-group discussions involving narratives, case scenarios, and role modeling by faculty. Professionalism of both students and faculties should be assessed and appropriate action taken.
Keywords: Medical education, perspectives, professional identity development, professionalism, role models, undergraduate medical students
|How to cite this article:|
Dhikale PT, Shrivastava SR, Srinivasan S. Perspectives about professionalism among undergraduate students in a medical college in India: A qualitative study. Indian J Community Med 2020;45:230-4
|How to cite this URL:|
Dhikale PT, Shrivastava SR, Srinivasan S. Perspectives about professionalism among undergraduate students in a medical college in India: A qualitative study. Indian J Community Med [serial online] 2020 [cited 2020 Nov 29];45:230-4. Available from: https://www.ijcm.org.in/text.asp?2020/45/2/230/285654
| Introduction|| |
Various regulatory bodies for doctors, worldwide have recognized the importance of professionalism, but have described it in different ways.,,,,, Professionalism is the basis of medicine's contract with society. According to the American Board of Internal Medicine (ABIM), six elements of medical professionalism have been identified, namely altruism (best interest of the patient), accountability (to patient, society, and profession), excellence, duty (commitment to service), honor and integrity (being truthful, meeting commitments), and respect for others (patients and their families, other physicians and professional colleagues such as nurses, medical students). The General Medical Council (GMC) links professionalism with being a good doctor.
According to the Medical Council of India (MCI), an Indian Medical Graduate (IMG) must be able to perform 5 roles one of them is a professional who is committed to excellence, is ethical, responsive and accountable to patients, community, and profession. MCI is planning to explicitly teach professionalism to medical students. The 2012 regulations of MCI for the first time included orienting medical students to professionalism as one of the objectives of the foundation course and early clinical exposure.
For the planning of a professional development program, we should have knowledge about the perceptions about professionalism among medical students. It is very important to learn the factors promoting and hindering professionalism from a medical student's point of view, well before planning the professionalism development program. Further, it is important to note that professionalism is not explicitly taught to medical students in colleges and till date there has been no study in India aimed to assess their perspectives on it. This study was done to explore the perceptions of medical undergraduate students and to assess their attitude on professionalism.
| Materials and Methods|| |
The study was done in a private Medical College in Pondicherry among undergraduate students from 1st year to final year of MBBS between September 2017 and March 2018.
Data collection was done by conducting four focus group discussions (FGDs) among medical students. One FGD was conducted for each year of course among 2nd, 4th, 6th, and 8th semester students). The medical students who were vocal were selected as participants for the FGD. In each FGD, there were 10 participants (5 boys and 5 girls). The FGDs were facilitated by the principal author who is trained in qualitative research methods. The FGD guide consisted of broad, open-ended questions on the qualities of a good doctor, need and ways of teaching professionalism to medical students, evaluating professionalism, and factors promoting and hindering professionalism. The FGDs were audio-recorded and transcripts were prepared verbatim.
Manual content analysis of the transcripts was done. Inductive codes were derived from the transcripts. Deductive codes were mainly derived from the competencies for IMG given by MCI and the FGD guide. Similar statements were merged to form codes, while similar codes were merged together to form the categories, and finally, similar categories were merged to form themes.
Ethical issues involved in the study
Clearance from the Institutional Ethics Committee was obtained. Written informed consent was taken from each participant. Confidentiality was maintained.
| Results|| |
The text information was categorized into 27 categories which were merged into seven major themes.
Theme A: Qualities of a good doctor
The following categories were included in this theme.
Committed to excellence
A good doctor should have adequate knowledge of the subject and should keep subject updates. He/she should be able to provide basic treatment to patients and handle emergency situations.
Responsive and accountable to patients
The students felt that a good doctor should be regular, punctual, and confident yet humble. She/he should build rapport with the patient and treat them respectfully and maintain confidentiality. He/she should be compassionate but not get too emotionally attached to the patient.
Responsive and accountable to the profession
A final year student quoted “The doctor-doctor relationship is also important. Like if one doctor has diagnosed a patient other doctor should be able to explain why that doctor might have diagnosed that way and why you think the diagnosis is different. The doctor should not unnecessarily blame another doctor for the good of doctor community.” The doctor should refer the patient to another doctor if he feels necessary.
A good doctor should prioritize his professional duties before his personal commitments, as it is a basic expectation of society from any doctor. She/he should treat emergency cases irrespective of their duty hours.
Ethical and law abiding
Students opined that as per guidelines of the MCI, doctors should follow the Hippocratic oath, have proper professional conduct and should at least not to be negligent.
An eighth semester student quoted “It is very important, no matter what happens at the end of the day you believe that what you are doing is right and you stand true to your word and you should follow it.” They should not prescribe unnecessary, drugs, and investigations.
A doctor should think his work as social, noble work and treat all patients equally irrespective of caste, religion, and socioeconomic status. Doctor should not charge or charge less from poor patients.
Responsive and accountable to community
Doctors should take into account the cultural practices and sensitivities while communicating and managing the patient. Doctor should try to minimize patients' expenses.
Health and appearance
A final year student quoted “Doctors” health is important. If a doctor is morbid obese how can he advice about healthy lifestyle, diet. If he himself wears shabby clothes he himself is a source of infection.” A sixth semester student said “Doctor should be physically and emotionally fit.” All students said that doctors should not drink alcohol during the duty hours.
Many students of the eighth semester felt that appearance, clothes and language are very important for a doctor. A doctor with spectacle is considered more knowledgeable.
A final year student quoted “Looking neat and looking sharp is also an important aspect. Patients expect doctors should have a clean shave, should wear formal clothes and not T-shirt and Jeans.”
However, another student replied “It is more important to properly diagnose and treat the patient rather than doctor's appearance.”
First year students felt that a poor communicator can also be a good doctor. A student said a medical counselor can be kept to explain to patients as doctors are very busy to talk with patients. A 1st-year student shared his experience “Some doctors will put a board at the reception itself; patients should not ask questions as doctors do not have time. A specialist doctor in the city does not let the patient talk. He will charge Rs 200 for 2 min but he is the topmost doctor. He knows the mindset of people, i.e., doctor should diagnose correctly and quickly.” However, students from fourth, sixth, and final year felt that communication skills are important.
A final year student quoted “Yesterday in medicine ward, relatives of a patient who had undergone endoscopy said that the patient has pain and endoscopy was not necessary. I explained them why it was indicated and that the doctors are good, not to worry. What I felt was if doctors would have properly talked, explained to patients and relatives then this might not have happened. Communication skills of doctor are more important than his clinical skills.”
Theme B: Need for teaching professionalism
Most of the students said that it is necessary to teach professionalism to medical students, while some said it is not.
Reasons to teach professionalism
The students said that they come from different backgrounds, may need to work in different geographic areas and they may have incomplete information, so proper holistic teaching about professionalism is necessary. A doctors' profession has unique qualities and what not to do should also be taught. A 3rd-year student said “Learning by experience will take more time, so teaching professionalism we will learn it faster.”
Reasons for no need to teach professionalism
In all FGDs, some students said that we learn professionalism by observing our faculties, seniors, during postings, so it need not be taught. Some students were of the opinion that Professionalism cannot be taught. A 3rd-year student said “Teaching in theory does not make an impact, observing from doctors, teachers and mentors, role models is better.”
Theme C: Learning professionalism
Students said that they are learning professionalism presently from faculties, seniors, personal experiences, and media.
Faculties and seniors
Most students said they learned professionalism by observing their faculties during their lectures and clinical postings. They also learn from the experiences shared by their teachers, seniors and also take their guidance. An eighth semester student said “All students look upon their faculty. How they behave in the classroom. We notice all minute things all 150 pairs of eyes look upon them. Every action they do matters.” A student said “We follow teachers, seniors irrespective of it is good or bad.”
Students said they are learning about moral values since childhood from parents, school teachers. They have liked the behavior of some doctors so they try to behave accordingly.
The students shared that if the media ridicules some behavior of doctors they try to avoid it and praises some behavior they try to adopt that behavior.
Theme D: Ways of teaching professionalism
Students suggested following ways for teaching professionalism to the medical students.
Role modeling by faculties
Many students said faculties should demonstrate professionalism in their day to day action.
An 8th semester student said “All teaching faculties are perfect enough to teach. It should be more of everyday action rather than just class.”
Group discussion on scenarios
Many students said group discussion is better to learn professionalism. A final year student said “Scenarios can be given to smaller groups like of students like 10 so that inhibition will not be there so that they can interact.”
Interaction with highly successful doctors
A sixth semester student said that doctors who have accomplished great success should be called for lectures and discussion. Other students supported this view.
Theme E: Assessing professionalism
Many students said that it is difficult to assess it. Some students said confidential feedback is important for student's improvement. Some students said outpatient department (OPD) attendance of a doctor is an indicator of his professionalism, but others differed saying there are many other factors which decide number of patients in OPD.
Theme F: Factors promoting professionalism
According to medical students following factors encourage them to be a good doctor.
Family, relatives and friends
They look on them for minor illnesses and motivate them to become a good doctor. They do not mind even if they do not attend important functions like marriage due to studies.
Some movies criticize doctors. In newspaper also, we read stories of negligence by doctors we want to make a good public opinion about doctors. Students feel motivated when they read success stories in newspapers or biography of a good doctor.
Patients share their problems, trust them and they feel encouraged.
Praise from faculties, colleagues, patients, relatives encouraged them.
The good tradition of this noble profession encourages students to follow it.
Theme G: Factors hindering Professionalism
According to medical students, monitory aspect, unfair practices, and other social factors hinder them from becoming a good doctor.
A final year student said “To complete MBBS in management quota the expenditure is a crore. There is pressure that parents have spent so much money and we need to get that money back and pay the debts.”
Some students said favors given by pharmaceutical companies hinder professional behavior. A sixth semester student said he felt sad that “Pharmaceutical companies send Doctors on foreign tours, finance seminars, meeting to prescribe their medicines.” Another student said “Sometimes this degrades us. If other doctors are doing such wrong things, not getting penalized and getting rich, why should not we also become rich by similar ways.” Some students said that corporate hospitals want to make maximum profit and so they force doctors to extract more money from patients. Some students said few examiners take bribe from students to pass an examination in some medical colleges and this is a very unprofessional behavior.
The students perceived that female gender, caste-based reservation system prevalent in society hindered them from becoming a good doctor. A final year girl student said “we can't take any subject in post-graduation. We have to take obstetrics and gynecology or pediatrics. If I want to do practice, parents and relatives will say you have to marry.” Some students said that entrance examination cut-offs are much different for different castes and this hinders professional behavior. The violence against doctors, negative media coverage is also important hindrances. Some students said students who have taken profession due to parental pressure do not have a passion for this profession and may not behave professionally. Students felt that the concept of the family doctor who used to have good rapport with patient is decreasing which discourages them. A 6th semester student said “After studying for 5.5 years of MBBS people say you are not eligible to treat me, it is not encouraging.”
| Discussion|| |
The students perceived that a good doctor should be committed to excellence, responsive and accountable to patients, profession and community, selfless, healthy, good communicator, ethical and law abiding, practice integrity, and social justice.
While most of the qualities of good doctor shared by the students in FGDs of all years were similar, the final year students emphasized more on the importance of communication with patient, appearance of the doctor and responsiveness and accountability to the profession. The 1st-year students were not aware about the importance of communication, but all other year students knew the importance of communication. The reason for this might be that 1st-year students didn't have any exposure to clinical postings while final year students had maximum exposure to clinical postings. MCI includes communicator as one of the six roles of IMG. The findings of two qualitative studies done in Pakistan and Turkey among undergraduate medical students suggested that students suffer from a gradual erosion of perception of professionalism during medical education, but there were no such findings in our study, may be due to different socio-cultural context.,
Most of the eighth semester students said that doctors should be clean shaved and have formal clothes as per society's expectations, but some of them felt sorry that doctors with modern look like trendy beard are ridiculed by society. In a cross-sectional study conducted in a government hospital in New Delhi majority of the patients preferred formal dress for the doctor. This college is in rural Puducherry where traditional descent dressing and hairstyle are respected by people.
All the qualities and competencies mentioned under the role of professional required by IMG as per MCI were described by the medical students with the additional quality of being healthy. The quality of maintenance of personal health is not included in MCI roles and competencies for IMG. As per the CanMEDS, as professionals, physicians are committed to the maintenance of personal health.
The perceptions of students about professionalism are also in accordance with the three fundamental principles of professionalism given by the ABIM, namely Principle of primacy of patient welfare (Altruism), Principle of patient autonomy, and Principal of social justice. The perceptions of students about professionalism are also in accordance with GMC concept of good doctor.
Most of the students said that it is necessary to teach professionalism to medical students for holistic and quicker learning of this important concept. Some students told professionalism can be learnt from observation of faculties and clinical apprenticeship alone. However, role modeling alone is no longer sufficient to teach professionalism. It is now globally agreed that professionalism is a core competency for physicians,,,,, and should be taught explicitly.,,
Students said that they are learning professionalism presently from faculties, seniors, personal experiences and media. Some medical experts also opine that some elements of professionalism will be learned by student during their upbringing from childhood., The medical colleges should nurture professionalism; society should have a culture of professionalism.,,,
Students' preferences for different learning methods should also be considered for teaching professionalism. According to students, mainly small group discussion on case scenarios and role modeling by faculties should be used for teaching professionalism, alongside case-based interactive teaching methods., Small-group discussions involving case vignettes, video clips, narratives to teach different aspects of professionalism should be used and students should feel safe to reflect on it.
Many students said faculties should demonstrate professionalism in their day-to-day action. Professional role models can also display unprofessional behavior, a leading cause of the well-documented cynicism which can develop in some students. Many students said it is difficult to assess professionalism, but they knew the importance of feedback. Both teaching and evaluation of professionalism is best done in a longitudinal fashion, by different methods, and across different contexts, since professionalism is context specific.
The students perceived that the media gives greater coverage for few unprofessional acts of doctors negatively affecting peoples trust, but they also feel motivated to change this image and are positively influenced by the success stories of doctors in the media. Some students perceived that lack of consequences for those who engage in unprofessional behavior discourages them from becoming a good doctor, a similar view was expressed by Gliatto and Stern.
The data are from one private medical college in India and may not be representative of views of students of all medical colleges in India.
| Conclusion|| |
Some elements of professionalism are learned by students during their upbringing from childhood. Medical undergraduate students should be briefed about the need and importance of Professionalism and it should be taught explicitly to them. It can be taught by small-group discussions involving narratives, case scenarios and role modeling by faculty. In addition, professionalism of both students and faculties should be assessed and appropriate action should be taken.
We would like to thank the principal for giving permission and students for participating in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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