The core of professionalism constitutes "… those attitudes and behaviors that serve to maintain patient interest above physician self-interest. Accordingly, professionalism … aspires to altruism, accountability, excellence, duty, service, honor, integrity, and respect for others" (1).
Ethics is an endeavor. It refers to ways of understanding what is good and right in human experience. It is about discernment, knowledge, self-reflection, and it is sustained through seeking, clarifying, translating. It is the concrete expression of moral ideals in everyday life. Ethics is about meaning, and it is about action (2).
Professional attitudes and ethics skills of physicians are shaped in part by the lessons of medical training (3, 4). Suturing a wound, assisting in the delivery of a newborn baby, caring for a dying person, setting a bone, writing a prescription—and confronting limitations as a person and healer—are defining moments in the professional lives of medical students and residents (5). Beyond these lived lessons of medical training, formal curricula have been widely introduced in medical schools and residency programs over the past three decades to enhance the professionalism and ethical strengths of early career physicians (6—11). Medical trainees are increasingly required to demonstrate competence in these domains, and a call has been made for educational initiatives in professionalism and ethics that are rigorous, valid, and seamlessly integrated across undergraduate and graduate medical education (7, 12—17).
Small empirical studies involving medical students and, to a lesser extent, residents over the past two decades show that trainees see the need for professionalism and ethics teaching (18—22). Medical students and residents express interest in diverse ethics topics and strongly endorse the practical value of preparation for ethical decision making (18, 21,23). Attitudes toward professionalism and ethics related skills vary somewhat according to gender, level of experience, and clinical interests (12,18—26). Worrisome results have emerged suggesting that sensitivity to identifying ethical problems in clinical care may diminish as trainees progress through their education (21, 27—30). This further suggests that compassion may be eroded in the course of medical training and be replaced by cynicism, psychological detachment, and objectification of ill persons (31—33).
Early work suggests that positive attitudes of physicians-in-training toward professionalism and ethics preparation improve beneficial outcomes of educational innovations (25, 35, 36). For example, house officers' positive views of the quality of their ethics training were associated with confidence in dealing with ethical conflicts (37). Such findings support the belief that assessing trainee attitudes, views, and preferences is important in developing curricular approaches attuned to their concerns and experiences (38—40). This information may help in the creation of curricular content and methods that are more acceptable to trainees (20, 21, 32, 41, 42). Most importantly, these data may assist in creating teaching and evaluative strategies that improve the care practices of our early career colleagues, as demonstrated in the introduction of HIV-related and preventive health curricula (43, 44).
Taken together, these small, distinct projects suggest the importance of further evidence-based inquiry related to professionalism and ethics curricula for medical students and residents. Little empirical work has been conducted on professionalism, and no studies have directly compared the attitudes and views of medical students and residents toward professionalism and ethics curricula in an integrated analysis (18, 45, 46). Additionally, no study analyzing differential views of medical students and residents related to competence and the need, value, appropriateness, content, goals, or methods of professionalism and ethics teaching and assessment was found. To remedy this gap, we conducted a comprehensive survey of medical students and residents concerning their views on professionalism and ethics education.
All medical students (N = 308) and PGY1-3 residents (N = 233) at the University of New Mexico School of Medicine in the Spring of 2000 were invited to participate in this survey study. At UNMSOM, professionalism and ethics are taught through didactics, small group sessions, and individual supervision. At the time of this study, professionalism and ethics were evaluated during three performance-based examinations of medical students and were part of all supervisor evaluations for medical students and residents (51—53).
Three of us (L.R., T.W., C.G.) developed a survey to assess views of professionalism and ethics preparation and their assessment in medical education. The American Board of Internal Medicine (ABIM) definition of professionalism, which is consistent with the definition first quoted at the beginning of the introduction, was used to shape the major domains and to guide construction of items for the instrument. The survey included eight demographic questions and 124 content items in 10 domains: attitudes, goals, learning methods, curricula, knowledge assessment, skills assessment, informed consent topics, principles, vulnerable populations, and relationship boundaries. Content items were each rated on 9-point scales appropriately labeled. The first 6 domains are reported here.
The survey was sent via campus mail with a cover letter indicating the purpose of the study, confidentiality procedures, and institutional review board approval. Two follow-up mailings were sent to nonrespondents at 1-month intervals. Medical students received $10 in compensation for time and effort. Residents received $20.
To assess reliability, a random subset of 30 respondents completed the survey again 7 weeks later. Retest correlations ranged from -0.03 to 0.81 (mean r = 0.51, p<0.05) with correlations above 0.25 for 54 of 58 items.
Separate analyses were conducted for each survey domain. Responses were subjected to repeated measures (comparing item ratings within domains) multivariate analyses of variance (MANOVA) using gender and training level (preclinical medical students versus clinical medical students versus residents) as independent variables. Some items were averaged into composite variables based on conceptual coherence and factor analyses. Further analyses examined ethnicity and residency program group (psychiatry versus other specialties versus primary care programs) as additional independent variables.
Sixty-two percent of trainees (N = 336) responded (t1). Respondents were: 51% women, 20% Hispanic American, 61% "Anglo/white," and 19% other or unreported, including 1% African American, 5% Asian American, and 4% Native American. No systematic differences in survey responses were found for ethnicity. Training level groups did not differ significantly by gender or ethnicity. The proportion of respondents married or living with a partner increased with advancing level of training (40% for preclinical students, 61% for clinical students, 63% for residents, p<0.01) as did age (mean = 27.8 [SD = 4.0], 29.5 [SD = 4.7], and 32.5 [SD = 4.8], respectively; p<0.05). Fifty percent of residents were in primary care departments, 13% in psychiatry, and 38% in other specialty departments.
Experience With Ethical Conflicts and Ethics Training
Trainees rated (scale of 1="never" to 9="constantly") the degree to which ethical conflicts were encountered during their training (t2). Trainees reported experiencing a moderate level of ethical conflicts (mean = 5.49, [SD = 1.81]), with 58% of respondents indicating high frequency of encounters with ethical conflicts (rating of 6, 7, 8, or 9). Trainees with clinical experience reported more ethical conflicts than did preclinical trainees (preclinical mean = 4.50, clinical medical student and resident means=5.99, Cohen's d=0.83, training level main effect, F = 23.54, df = 2, 330, p<0.0001). Women (mean = 5.73) reported more conflicts than men (mean=5.25, d = 0.26, gender main effect, F = 5.90, df =1, 330, p<0.02).
Trainees reported moderate helpfulness of medical education in dealing with ethical conflicts (mean = 4.75; scale of 1 = "not at all" to 9 = "very much," [SD = 1.94]), with 40% of respondents indicating high helpfulness of medical training (rating of 6, 7, 8, or 9). Clinical medical students and residents reported greater helpfulness of medical education than preclinical students (preclinical mean = 3.87, clinical mean = 5.20, residents mean = 5.17, maximum d = 0.69, training level main effect, F = 16.02, df = 2, 330, p<0.0001).
Trainees reported receiving a moderate amount of training in ethics (mean = 4.43; scale of 1 = "none" to 9 = "very much," [SD = 1.85]), but mildly disagreed that the training received was adequate to handle ethical conflicts (mean = 4.07; scale of 1 = "strongly disagree" to 9 = "strongly agree"). Clinical medical students reported more ethics training than did residents or preclinical students (clinical students mean = 5.04, preclinical students mean = 4.26, residents means = 3.98, maximum d = 0.58, training level main effect, F = 10.19, df = 2, 330, p<0.0001). Clinical medical students also reported more adequate training to handle conflicts than did either residents or preclinical students (clinical students mean = 4.54, preclinical students mean = 3.80, residents means = 3.88, maximum d = 0.43, training level main effect, F = 5.87, df = 2, 330, p<0.01). Only 18% of trainees found ethics training adequate (rating of 6, 7, 8, or 9).
Attitudes Concerning Ethics, Professionalism, and Values in Medical Training
Trainees rated agreement (scale of 1 = "strongly disagree" to 9 = "strongly agree") with statements about aspects of training in the domains of professionalism, ethical issues and conflicts, ethics education, and influence of medical training (t3). Domain composite measures were differentially supported (composite main effect, F = 250.53, df = 3, 321, p<0.0001). Trainees strongly affirmed the importance of professionalism (mean = 7.79, [SD = 1.09]), the presence of ethical issues and conflicts (mean = 7.75, [SD = 1.03]), and the appropriateness of ethics education (mean = 6.72, [SD=1.32]). Women expressed stronger agreement than did men overall with statements about professionalism (means = 7.97 versus 7.61, d = 0.33, p<0.01), ethical issues and conflicts (means = 7.96 versus 7.55, d = 0.40, p<0.001), and ethics education (means = 6.87 versus 6.58, d = 0.22, p<0.05). Scores for professionalism, ethical issues and conflicts, and ethics education were intercorrelated (r range 0.22 to 0.25, all p<0.0001).
The professionalism factor included three statements concerning possession of professionalism and its use in evaluation and selection. Trainees at all levels greatly endorsed these (means 8.49 to 8.70, [pooled SD = 0.85]). Residents endorsed professionalism as a criterion for evaluation and selection more than did medical students (resident means=7.84, medical student means = 6.98 to 7.37, mean d = 0.39, training level effect F=9.69, df = 2, 323, p<0.0001; item x training level interaction F = 4.17, df = 4, 644, p<0.01).
The influence of medical training factor included three statements. Respondents agreed that medical training fosters professionalism (mean = 6.32, [SD = 1.72]) and ethical behavior (mean = 6.15, [SD = 2.18]) but disagreed that medical training does not foster cynicism (mean = 3.67, [SD = 1.88], maximum d = 1.47; item effect F = 277.71, df = 2, 322, p<0.0001).
Relationship of Experience to Attitudes Toward Ethics Training
Variables representing experience with ethical conflicts and ethics training (t2) were correlated with scores of training related attitude factors (t3) overall and within training levels to examine the relationships among reported experience and attitudes. The reported degree of ethical conflicts was positively correlated with ethical issues and conflicts for all training levels, much more so for residents than medical students (preclinical students r = 0.22, p<0.04, clinical students r = 0.26, p<0.01, residents r = 0.53, p<0.0001). Reported ethical conflicts encountered were also positively correlated with professionalism for all trainees (r = 0.16, p<0.01), but negatively correlated with influence of medical training (r = —0.23, p<0.001). However, influence of medical training was positively correlated with participants' perceptions of the adequacy of training to handle ethical conflicts (medical students r = 0.20, p<0.05; residents r = 0.29, p<0.001), with training in ethics for clinical medical students (r = 0.23, p<0.02), and with medical education helpful in dealing with ethical conflicts for clinical trainees (clinical medical students r = 0.38, p<0.0001, residents r = 0.20, p<0.03).
Goals of Education in Ethics, Professionalism, and Values
Trainees rated (scale of 1 = "strongly disagree" to 9 = "strongly agree") educational goals concerning ethics, professionalism, and values (t4). Different goals were seen as differentially desirable (item effect F = 49.30, df = 4, 323, p<0.0001). Trainees strongly affirmed the goals of improving clinical care (mean = 7.51, [SD = 1.55]), recognizing ethical issues (mean = 7.43, [SD = 1.25]), developing ethically useful interpersonal skills (mean = 7.25, [SD = 1.44]), and better clarification of values-laden choices (mean = 6.95, [SD = 1.59]) and affirmed the prevention of cynicism and detachment (mean = 6.00, [SD=2.09]) as a goal of education in professionalism. Women expressed stronger agreement with all goals, particularly improving patient care and developing relevant interpersonal skills (overall means = 7.28 versus 6.77, d = 0.42, Gender effect F = 14.82, df = 1, 326, p<0.001), item x gender interaction F = 2.57, df = 4, 323, p<0.04).
Learning Methods in Ethics Training
Trainees rated (scale of 1 = "strongly disagree" to 9 = "strongly agree") the effectiveness of various learning approaches (t5). And they were seen as differentially effective (item effect F = 111.26, df = 4, 313, p<0.0001). Trainees rated clinical approaches (role modeling by faculty, clinical rounds, interactions with patients, and case conferences) as the most effective (mean = 6.87, [SD = 1.28]), and multidisciplinary expertise approaches (discussions with cultural experts, ethics consultants, attorneys, and chaplains) as effective (mean = 6.54, [SD = 1.47]). Nontraditional (videotapes, discussions, and standardized patient interactions) and formal didactic approaches (grand rounds presentations and lectures) were considered only somewhat effective (means = 5.64 and 5.38 respectively, [pooled SD = 1.70]). Trainees rated independent approaches (independent and directed reading, ethics research with a mentor, and web-based education) as neutral (mean = 5.08, [SD = 1.79]).
Students at all training levels rated clinically-oriented learning approaches as highly effective (means = 6.82 to 6.95, [pooled SD = 1.26]). Role modeling by faculty was rated the most effective of the clinically oriented approaches, particularly by women (means = 7.82 versus 7.18, d = 0.34). The rated effectiveness of multidisciplinary, nontraditional, formal, and independent learning approaches decreased with increasing clinical experience, most sharply for nontraditional approaches (resident versus preclinical student d = —0.27, item x training level F = 2.87, df = 8, 626, p<0.01). Trainees rated interactions with standardized patients as the least effective of the nontraditional approaches, with ratings decreasing with greater clinical experience (preclinical student mean = 4.91, clinical student mean = 4.13, resident mean = 3.51, [pooled SD = 2.26], maximum d = 0.62, item effect F = 156.99, df = 3, 314, p<0.0001, item x training level interaction F = 4.09, df = 6, 628, p<0.001). However, the large SD (2.26) for training with standardized patients indicates considerable disagreement among respondents for this measure. Women rated all approaches higher than did men, particularly multidisciplinary expertise (means = 6.02 versus 5.78, d=0.21, gender effect F = 3.43, df = 1, 316, p<0.07, item x gender interaction F = 3.49, df = 4, 313, p<0.01).
Methods of Assessing Skills and Knowledge
Trainees rated agreement (scale of 1 = "strongly disagree" to 9 = "strongly agree") that various clinical supervision or structured assessment methods are appropriate for assessing knowledge and skills related to professional attitudes, values, and ethics (F1). All trainees strongly agreed that clinical supervision is appropriate but were neutral that structured assessments (oral, written, and multiple choice exams, essays, standardized patient interactions, analyzing trigger videos, and faculty observation of videotaped interactions) are appropriate (clinical supervision means = 7.09 and 6.85 for knowledge and skill assessment, structured assessment means = 4.86 and 4.77, [pooled SD = 1.77], maximum d = 1.25, knowledge versus skill effect F = 7.05, df = 1, 317, p<0.01, assessment method effect F = 376.44, df = 1, 317, p<0.0001). The rated appropriateness of clinical supervision for knowledge assessment increased across training levels (preclinical medical student mean = 6.90, clinical medical student mean = 7.08, resident mean = 7.30, maximum d = 0.23). Medical students rated the appropriateness of structured assessments neutrally, but residents found them inappropriate for assessing either skill or knowledge related to professionalism and ethics (medical student mean = 4.90 to 5.34, resident mean = 4.08 to 4.28, maximum d = 0.71, training level effect F = 4.35, df = 2, 317, p<0.02, knowledge versus skill x training level interaction F=2.93, df=2, 317, p<0.06, assessment method x training level interaction F = 12.59, df = 2, 317, p<0.0001). Trainee views of structured assessment involving standardized patients declined from neutral for clinical medical students to inappropriate for residents (preclinical medical student means = 4.70 to 4.80, clinical medical student means = 4.03 to 4.37, resident means = 3.50 to 3.90, [pooled SD = 2.38], maximum d = 0.56).
Residency Program Comparisons
Resident trainee responses in the domains of experience, attitudes, goals, and learning and assessment methods were analyzed with residency program group (psychiatry versus other specialties versus primary care programs) and gender as independent variables. Results for experiences and attitudes (items in t2 and t3) generalized across program groups, except that psychiatry residents reported receiving more training in ethics (respective means = 5.11 versus 3.69 to 3.86, maximum d = 0.69, p<0.04) and agreed more with attitudes concerning ethics education (respective means = 7.54 versus 6.48 to 6.80, maximum d = 0.70, p<0.04). Psychiatry residents also agreed more with goals concerning ethics and professionalism (items in t4) than did residents in primary care or other specialty programs (means = 7.60 versus 6.62 to 7.19, maximum d = 0.77, p<0.01). Psychiatry residents rated learning approaches as more effective than did residents in other program groups (see F2; respective means = 7.02 versus 5.27 to 5.78, maximum d = 1.34, F = 11.41, df = 2, 126, p<0.0001), more so for nontraditional, formal didactic, and independent methods (item x residency program group interaction F = 2.875, df = 8, 504, p<0.01, maximum d = 1.55). Psychiatry residents also rated assessment methods as more appropriate than did residents in other program groups (means=6.60 versus 5.45 to 5.62, maximum d = 0.85, p<0.02).
This study offers a unique cross-sectional comparison of the perspectives of 200 medical students and 136 residents who strongly affirmed the importance of professionalism and ethics preparation in medical training. Ethical conflicts are seen as common, especially by women and advanced trainees. Interestingly, experience with ethical problems and attitudes toward appropriate education vary with training level. Respondents indicated that professionalism and ethics can be taught and learned and are appropriate curricular topics. The goals of such preparation are seen as related to improved patient care and clinical decision-making, recognition of ethical issues and clarification of values-laden choices, development of ethically important interpersonal skills, and prevention of detachment and cynicism. As anticipated, clinical students and residents more strongly endorse the helpfulness of professionalism and ethics preparation than preclinical students. All trainees overwhelmingly endorse the evaluation of professionalism in selecting applicants and evaluating physicians-in-training, a finding not reported previously in the literature.
Diverse learning approaches (e.g., clinically-oriented, multidisciplinary expertise-oriented, nontraditional formats) are valued by our participants. Clinically-oriented assessments of knowledge and skill (e.g., direct observation of trainee-patient or trainee-team interactions by faculty) are strongly preferred over structured assessments (e.g., standardized patient evaluations, written exercises), irrespective of level of training or gender.
The psychiatry residents in this sample were especially receptive to ethics education: they report that they have received more training, they endorse key attitudes related to the rationale for ethics and professionalism initiatives in medical education, they affirm several goals for ethics and professionalism preparation, they believe in the effectiveness of many learning methods, and they indicate that multiple assessment methods are appropriate. Nevertheless, it is worthy of attention that, overall, the participants in this study, including psychiatry residents, were mildly negative about the adequacy of current training practices.
Our findings lend strong empirical support for recent major educational initiatives introduced by academic leaders in medicine related to professionalism and ethics (54). These include efforts to develop more substantive curricula, the requirement for residents to demonstrate competence in this domain, and the inclusion of formal professionalism and ethics criteria in the selection of medical students and residents (17, 42—44, 46—53, 55—59).
The trainees in this study offer clear guidance for integrated educational and assessment methods that are attuned to their experiences and preferences. They are most enthusiastic about clinically-oriented and multidisciplinary expertise-oriented learning approaches, from role-modeling and ethics discussions during clinical rounds to incorporation of ethics and culture topics in formal lectures and consultation with ethics experts. Independent, individually-oriented learning approaches are seen neutrally, a finding that warrants careful consideration in light of the movement toward web-based education which may be experienced as isolative. These findings are intuitive for experienced medical educators who understand that the most poignant lessons of professionalism and ethics are those that are lived out, discussed, and made meaningful in clinical situations (3, 60, 61). This ecological approach to professionalism and ethics education extends to assessment. Medical students and residents, regardless of phase of training, view knowledge and skill performance evaluations that are clinically-oriented as much more appropriate than techniques remote from everyday patient care.
Women in our study identify a greater prevalence of ethical dilemmas in their work and more strongly endorse the positive role of professionalism and ethics preparation. This pattern replicates previous work (25, 62, 63). Reasons for gender differences in responses to professionalism and ethics in medical education, and how these differences may influence patient care, remain uncertain (64). These results are an invitation for further study.
The data from this project suggest that psychiatry residents may be especially receptive to ethics and professionalism preparation in medical education. Ethics and professionalism were viewed as important, and residents were accepting of diverse learning and assessment methods. We believe that these results may be representative of psychiatry residents elsewhere, as they echo the responses in a similar survey study involving 180 psychiatry residents in a convenience sample of ten U.S. programs performed by one of us (L.W.R.) with colleagues more than a decade ago (23). The affirmation of ethics and professionalism training by psychiatry residents should serve as an invitation to academic faculty to create intensive, innovative educational initiatives in this domain. In the future, failure to respond to this invitation will certainly represent a 'missed opportunity' in terms of our trainees' learning as well as our fulfillment of ethically-important professional commitments in medical education.
Finally, for many years, medical educators and bioethicists have struggled with whether medical training imparts enhanced professionalism and ethical behavior or greater cynicism and ethical erosion (27,32,65). Our respondents believe medical training fosters both, and indicate that medical education alone does not assist them in resolving ethical conflicts. Professionalism and ethics preparation, however, may strengthen the capacity to identify, appreciate and manage ethical conflicts despite pressures that may lead to diminished ethical sensitivity (66). The trainees in this study are optimistic about the achievable goals of professionalism and ethics curricula, ranging from improved clinical decision-making to prevention of cynicism and detachment. While it has been frequently suggested that the aim of professionalism and ethics preparation is not to midwife virtue or to assure sound moral character, medical students and residents themselves believe it may confer positive qualities and preservation of compassion (3,5,12). This is an empirical question of considerable potential importance to the care of patients.
Limitations and Strengths
This study relies on self-reports and a sample from a single academic medical center in an underserved, largely rural state with a substantial minority population. The concordance of our findings with similar work and the absence of specialty-specific differences among resident respondents, however, suggest that the results may be generalizable (18,21,22,49,67). The cross-sectional design provides insights into developmental issues relevant to professionalism and ethics education in medicine but does not show changes as training progresses as permitted by a longitudinal design. The strengths of this study include the solid response rate, the comprehensiveness of the survey, and the examination of a substantial number of participants across three training levels in a single integrated analysis.