In the last few years, several important academic institutions, including the Association of American Medical Schools (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME), have defined professionalism as a core competency for medical students and resident trainees. If physicians have been expected to comply with specific professional standards since at least the 4th century B.C. (when the Hippocratic Oath was derived), the question is—why now? Has a shift of values occurred that deems professionalism a topic that must be explicitly addressed rather than just assumed, as in previous times?

According to a 2007 survey of 1,175 physicians between the ages of 50 and 65 years (1), 68% considered recent resident graduates as "less dedicated and hard-working" than physicians who entered medicine when they did. Interestingly, in an article written by a group of medical students that same year (2), the overriding theme was a disconnection between the professional values taught in formal curricular activities and those expressed informally between mentor and mentee in clinical environments.

Why is it that at the same time some older physicians perceive a lessening of professional commitment in their younger colleagues, medical students are struggling to define expectations for professional behavior? We decided to examine potential differences in the importance of certain aspects of professional behavior among three groups: attending psychiatrists, psychiatry residents, and medical students rotating through a third-year clerkship in psychiatry. We hypothesized that professional behavior might be perceived differently in these three populations, which could explain part of the aforementioned disparity.

To our knowledge, there is no definitive scale to measure professionalism (3). Our first step in preparing our survey was to review categories of professionalism identified by previous investigators. We searched the MEDLINE database using the keywords professionalism and medical student. Drawing from those articles that discussed the definition of professionalism (3—7), we made a list of four categories and defined specific items related to these broad areas:

We sent a survey to third-year medical students rotating through the psychiatry clerkship, psychiatry residents, and attending psychiatrists in the Department of Psychiatry at Wayne State University School of Medicine. We obtained basic demographic information and asked participants to rate the items related to professionalism on a Likert scale, with these rating options: Not At All Important, Somewhat Important, Neutral, Important, and Very Important (Table 1). Finally, we asked participants to rate the importance of various methods of developing professional behaviors on the same Likert scale (Table 2).

The Wayne State University Institutional Review Board approved the study, and completion implied informed consent. We used the Internet tool "Survey Monkey," and all responses were completely anonymous. Analysis was primarily descriptive, with hypothesis-testing limited to analysis of variance between the three sampled groups. Post-hoc tests used Tukey's method. We combined the items within each of the categories having three or more items and found high internal reliability for Personal Characteristics (0.92 for 13 items) and Interactions With Patients (0.85 for 5 items). The internal reliability for the six items related to the dimension Social Responsibility was lower (0.78), although, when we removed the item Managing Conflict of Interest, internal reliability increased to an acceptable range (0.81). This suggests that respondents did not consider this item as closely related to the broad construct of social responsibility and should likely be removed if this scale is used in the future.

The response rate was 78% (N=118), with answers submitted by 35 students, 41 residents, and 42 psychiatrists. Respondents were predominately male (53.9%) and European American (54.6%). The majority received training in the United States (70.2%).

Under the category Personal Characteristics (Table 1), combined scores were marginally significantly different (p=0.068) among medical students, residents, and attending psychiatrists. Individual items, however, showed greater difference between the groups. Students rated the following items as relatively less important: Internal Motivation, Commitment to Lifelong Learning, Knowledge of One's Own Limits, Avoiding Abuse of Power as a Physician, and Adherence to Ethical Principles. Interestingly, but maybe not especially surprising, attending psychiatrists rated Punctuality as significantly less important. There was also a trend for lower mean scores on Attendance and Appearance among attending psychiatrists.

Medical students rated Interactions With Patients as significantly less important than the other two groups sampled (p=0.002). Contributing to this difference is the significantly lower mean scores that medical students gave Placing Patients' Concerns Before One's Own and Respect for Patients as Individuals.

Students' mean scores were also lower than those of residents but not those of attending psychiatrists for Social Responsibility. Medical students rated Treating the Underprivileged significantly lower in importance, but there was no difference in mean scores for Interactions With the Healthcare Team.

When rating methods to develop professional behaviors (Table 2), medical students chose "awarding those who demonstrate superior professional behaviors" and "direct observation and modeling of behaviors" as the most important factors for developing professionalism. Residents and attending psychiatrists rated individual mentoring as the most important. Medical students rated all categories in this area less important than residents and attending psychiatrists.

It is vital to emphasize that the majority of mean ratings were above 4, indicating that all groups studied felt that most items defining professional behavior were important or very important. There were some exceptions to this general statement: Appearance, among attending psychiatrists; Placing Patients' Concerns Above One's Own, for medical students; and several items related to Social Responsibility in both medical students and attending psychiatrists.

Resident physicians had the highest mean score in every category measured. The reason for this is unclear, because the evaluation process for both residents and medical students at our institution include professional behavior as a core competency. Perhaps the highly-regulated training environment in residency contributes to this difference. Also, our training program may place significantly more stress on this area. Additional explanations could be residents' idealism as they enter formal practice and their newfound direct responsibility for patient care.

Overall, medical students rated most items related to professionalism as less important than the two other groups surveyed. Perhaps internal motivation and knowledge of limits are difficult to achieve in a clinical environment where the student is often told explicitly how to perform throughout the day and commitment to lifelong learning is not yet realized as an important task. Adhering to ethical principles, although often included in formal preclinical activities, is typically strengthened by practice versus theory. The third-year students in this survey were just beginning to practice medicine in a clinical setting and may not have fully integrated ethical lessons from didactics. Given recent work-hour restrictions, putting patients' concerns above one's own might be viewed as a paradox (8). It is more difficult to hypothesize why students rated Respect for the Patient as an Individual as less important than the two other groups surveyed. This group as a whole is younger, and differences in ratings may reflect the students' level of maturity. Other factors not explored in this preliminary study may also explain these findings.

Both medical students and attending psychiatrists rated items related to Social Responsibility as less important. This could be because residents in our department are immersed in the clinical care of patients with low socioeconomic status. Our medical students rotate through a range of settings during their third year and are exposed to a diverse patient population. Likewise, attending psychiatrists care for patients with diverse financial status.

Regarding the development of professional behaviors, all groups surveyed focused on the relationship between mentor and mentee as more important than formal assessment and structured activities such as didactics and ceremonies. These findings suggest the importance of the clinical environment, where informal interaction between mentor and mentee is most evident, in the development of professional behavior. The fact that medical students rated all of the methods used to develop professionalism as less important than the other two groups is worthy of note. This may highlight the difficulty they have identifying the correct venue to learn about how to become a "professional" when the formal and informal curricula diverge.

Limitations of this study include unknown validity of the scale and a small sample size from one institution. Also, we focused on medical students during the psychiatry clerkship, psychiatric residents, and psychiatrists, and therefore cannot generalize our results to other specialties. The effect of influences such as level of maturity, gender, and training were not examined in this small sample, but they should be in future studies. Although complete anonymity was maintained, faculty members involved in both medical student and resident education were sent the survey, and therefore there may be a bias toward answering questions in a positive manner. Also, those who responded to our survey may be inherently more "professional" than those who did not, introducing another potential upward bias in scores.

In conclusion, although differences exist between medical students, residents, and attending psychiatrists, all three groups surveyed consider professional behavior to be important. Medical students rated more items related to professionalism as less important than residents and attending psychiatrists. Perhaps older physicians are sensing this variance. Although some of these differences are readily explained, others need clarification. The mentee—mentor dyad is considered the most important mechanism for developing professional behavior by medical student, resident, and psychiatrist alike. This relationship is essential and must be strengthened as younger colleagues struggle to define their "professional" identity.

Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer-review, applied to all manuscripts. Also, the editor is recused from any editorial decision-making.