Attitudes of Pakistani and Pakistani heritage medical students regarding professionalism at a medical college in Karachi, Pakistan

Professionalism has been regarded as a selection of core competencies of physicians since Hippocrates’ time [1, 2]. In recent decades, medical profession has increasingly been criticized for erosion of professional and ethical values [3, 4]. The reasons for decline in the aforementioned core competencies of physicians include changes in health care delivery patterns, technological advances, and challenging initiatives such as quality assurance and evidence-based medicine [5–8]. The medical community has responded to this criticism by an increased interest in conserving, advancing, researching, teaching, and evaluating professionalism in both education and practice areas [2].

The word “Professionalism” is derived from the Latin professio, or public declaration [9]. Though originally referring to open declaration of a religious belief, the term is used to characterize the values, behaviours and attributes professed by individuals involved in the practice of a specific field [2, 10]. Several organizations engaged with physician education and training such as the American Board of Internal Medicine, the European Federation of Internal Medicine, the Accreditation Council for Graduate Medical Education, and the American Association of Medical Colleges have listed those essential elements of Professionalism which an individual physician must possess. Despite some variation, the common attributes defined by various organizations include altruism, respect, compassion, integrity, accountability and commitment etc.; building on the foundation principles of patient welfare, autonomy and social justice [11–14].

It has now become the current emphasis of medical educationists that professionalism must be taught explicitly during undergraduate medical studies [3, 15, 16]. There is a substantial amount of scientific literature that proposes how to formally teach professionalism during preclinical as well as clinical years at medical schools [2, 14, 17, 18].

A number of studies have also provided examples of how different medical schools have incorporated professionalism in their curriculum which includes teaching professionalism as a longitudinal theme throughout the duration of the medical curriculum, teaching humanistic elements of professionalism by specially designing an elective course or by utilizing existing subjects such as Gross Anatomy, and involving local stake holders to suggest professional competencies and hence connect to cultural contexts [8, 19–21].

Assessment research to identify what effect such efforts have on student and resident practice have found promising results. A study from the Netherlands on intensive care fellows identified the importance of both formal and informal methods for learning professionalism with the need to expand formal methods [22]. A medical school in Ireland received outstanding professional results from second year medical students who were taught professionalism in an interdisciplinary style [23]. Similarly teaching biomedical ethics as an integrated medical curriculum was found helpful in providing medical students professional insights [24].

Research has indicated that an evaluation of students’ existing perceptions toward professionalism is critical for the development of courses aimed at improving professional behavior [25]. However, professionalism is still not taught explicitly in medical colleges and medical universities in Pakistan and therefore the need for formal inclusion of a curriculum on professionalism in both pre and post graduate medical education in Pakistan has been highlighted [26]. To the best of our knowledge, this is the first study from Pakistan describing perceptions of students regarding professionalism. While the primary aim of this study was to assess attitudes of Pakistani and Pakistani heritage students at a medical college in Pakistan about important elements of professionalism that an ideal medical doctor should possess, a further objective of the study was to determine students’ preferred ways of learning professionalism.

A written survey was distributed to undergraduate medical students at a public sector medical college in Karachi, Pakistan in the year 2011. The duration of the Bachelor of Medicine and Bachelor of Surgery (MBBS) course in Pakistan is five years. We contacted semester 1, 5 and 8 medical students to have representation of both pre-clinical and clinical years. The students were approached at the beginning of lecture and were explained about the study objectives and that the details of study and informed consent related information were given at the beginning of the study questionnaire. Students were free to fill out the questionnaires anonymously or return them without answering. At the end of the lecture, questionnaires were distributed to the students. One hundred and twenty seven students answered the survey questionnaire. The Penn State College of Medicine (PSCOM) Professionalism Questionnaire, which has been developed in Pennsylvania USA, was used after obtaining permission for its use from the author [25]. We decided to use this questionnaire because assessment of professionalism is relatively a new area in the field of medical education and only a few of the available instruments for its assessment are validated. Students at the study site were not taught professionalism explicitly. We inquired their current perceptions on the topic with the help of PSCOM Professionalism Questionnaire. This questionnaire had statements on elements of professionalism and students were given a five optioned rating scale of importance to judge the extent of their view of professional values. Numerous studies have used this strategy of provision of some references to students while trying to gauge their view-point on professionalism [27–29].

We did some slight modifications in the demographic section of the PSCOM Professionalism Questionnaire. The demographic questions now include each student’s study year, gender, age, and citizenship. For assessing main elements of a professional behaviour i.e. Accountability, Altruism, Duty, Excellence, Honesty & Integrity and Respect, six randomized sets of statements were provided. The students were asked to rate the degree to which each statement corresponded to their definition of professionalism on a five-point Likert scale (1 = never, 2 = little,3 = some, 4 = much, and 5 = great deal). For example, for assessing the element “Honesty & Integrity”, a total of six statements were distributed in random manner throughout the different sets of statements. One of these statements is as follows: an ideal medical doctor “Upholds scientific standards and bases decisions on scientific evidence and experience”. The students were required to choose from the above-mentioned Likert scale options how important that element of professionalism was to them. The maximum score for the statement was 5, for the whole set of statements related to the honesty and integrity element it was 30 and the maximum overall score for all professionalism related elements was one 180. To achieve the second objective of the survey, an additional question regarding preferred method for study of professionalism was added to the survey questionnaire. The options provided with this question were chosen from the published literature on professionalism teaching. The survey was pilot-tested on the undergraduate medical students of a different public sector medical college (n = 5) in Karachi. As a result of pilot testing the further rank ordering of the relative importance of items contained in the original PSCOM Professionalism Questionnaire was removed as students found it difficult and time consuming.

This study describes the attitudes of medical students toward professionalism at one medical college in Pakistan using the PSCOM Professionalism Questionnaire. The study also highlights approaches that have been found valuable for learning professionalism by the students.

Prior work that had used the American Board of Internal Medicine foundational elements of professionalism for assessing student opinion has found that all student groups agree upon these elements [31, 32]. The finding of no significant difference among the professionalism related elemental or overall score among our survey classes could partly be explained due to the fact that in Pakistan no formal activity or course aimed at enhancing professionalism is carried out in undergraduate medical curriculum. Professionalism rather is considered as an attribute that is implicitly learnt by students during their medical school and hospital training years. A study that had followed students over their course of pharmacy training had identified an increase in professionalism scores in later years. This increase was probably due to the inclusion of several professionalism related curricular and co-curricular activities in the course over time [33]. Since this was the first ever study to measure professionalism scores in Pakistan, no comparison values were available. The results of this survey can be used as a base line for assessing time trends or after any intervention regarding inclusion of professionalism in the undergraduate medical curriculum.

One of the strengths of our survey is the composition of our student sample, which includes Pakistani born and bred students as well as students who have had their high school education in the USA, Canada, and other countries. Our findings indicate that irrespective of place of high school education, all Pakistani and Pakistani heritage students have rated aspects of professional behavior as equally important for a medical doctor. There is currently a wealth of evidence from the west that highlights the importance of professionalism from the students’ viewpoint [34–36].

The need for medical schools and teaching hospitals to work continuously on developing and maintaining a high degree of professionalism has been stressed by other studies [37, 38]. One of the strategies to inculcate professional ethics among students is to consider their own view on how best this should be taught [34]. In our study, the majority of students have considered role modeling as the most preferred method for learning professionalism. Role modeling by teachers or senior colleagues is considered as an extremely powerful instrument for passing on professional values among medical students as well as residency trainees [39–41]. Some other researchers have argued that the traditional role modeling technique is no longer sufficient, and hence other approaches for teaching professionalism may also be considered such as teaching cognitive-based structured sessions for experiential learning, having formal evaluations, and faculty development activities [15, 42].

The other most preferred methods for learning professionalism in our survey were the use of case-based scenarios and role-plays. Use of case-based scenarios for undergraduate medical teaching of professionalism has been advocated by other studies as well. These scenarios were found to improve students’ skills in dealing with ethical issues [43, 44]. A study by Ratanawongsa et al. [45] however has found that role-plays and standardized patient or video taped patient-physician interactions as the least-used and the least preferred methods for teaching professionalism by residents. This difference in findings may be due to the use of a different group as undergraduate students and residents may differ in their clinical exposure and judgment.

The students rated all the attributes of professionalism (Accountability, Altruism, Duty, Excellence, Honesty & Integrity and Respect) as important and there was no difference across the study years. Faculty role models, case-based scenarios and role-plays may be used to teach professionalism. We propose that the study should be replicated at other medical colleges of Pakistan so as to gain further insights to the views on professionalism held by a larger population of students.