Teaching and Learning of Professionalism in …

1 706 Annals Academy of MedicineTeaching and Learning of Professionalism in medical Schools N SivalingamTeaching and Learning of Professionalism in medical SchoolsN Sivalingam,1 MBBS (Mal), FRCOG, FAMM1 Department of Obstetrics and GynecologyInternational medical School, Seremban, MalaysiaAddress of Correspondence: Professor Dato Dr Sivalingam Nalliah, Department of Obstetrics and Gynecology, Clinical School, International MedicalUniversity,70300 Seremban, : is now worldwide consensus that the elements ofmedical Professionalism need to be enhanced and explicitlytaught in medical schools. medical schools in the UnitedKingdom (UK) have recently published a model for a coreethics reference to the medical professional as ahealer has evolved into the doctor playing the role of abiomedical scientist and charging fees for in medicine has traditionally been seen asan enactment of values and ideals for physicians in servingindividuals and populations, prioritising the interests ofthose they serve above their own.

2 With several global andexternal factors influencing the profession and theprofessionals, there has been an apparent erosion ofsustenance of the tenets of medical Professionalism . Medicalcurricula are being scrutinised so as to introduce a systemof checks and balances to maintain high levels ofprofessional behaviour and values amidst changingAbstractConcerns about Professionalism in medicine have made necessary the explicit Teaching andlearning of ethics, Professionalism and personal development. The noble profession of medicine,taken up as a calling by those who are expected to put the needs of the patient above their own,appears to have become a fees-for-service business model and trade. Parental expectations, thediminishing sense of responsibility in teachers, lack of role models, technological advancements,sub-specialisation and third-party involvement in the healthcare delivery system have beenidentified as reasons for these concerns.

3 The General medical Council in the United Kingdom,and other professional bodies in both Europe and the Americas, have emphasised the need toenhance the Teaching and Learning of Professionalism in medical schools, particularly thedevelopment of good attitudes, appropriate and competent skills, and the inculcation of a valuesystem that reflects the tenets of Professionalism in medicine. The medical curriculum will needto be scrutinised so as to introduce the subject of Professionalism at all levels of training andeducation. Barriers to Learning Professionalism have been identified and students need to beequipped to resolve conflicts and to put the needs of others above their Acad Med Singapore 2004;33:706-10 Key words: Curriculum development, Explicit Teaching , Professionalism in medicine, Threats,Trainingperceptions and altered health delivery systems.

4 To someextent, changes in individual value systems, third-partyinvolvement in medical care and the extensive use oftechnology have influenced decision-making in for Making the Teaching and Learning ofProfessionalism ExplicitOsler4 emphasised that the traditional Learning method,where the student, working in clinics and wards under theclose supervision of full-time faculty, was an effectivemaster-apprentice model in inculcating the elements factors today appear to be threateningprofessionalism in medicine, including the slowdisintegration of the medical community. In the UK,Tomorrow s Doctors5 was first published by the GeneralMedical Council in 1993, signalling a significant change inthe Learning process in medical medical Practice6 (published in May 2001 in theNovember 2004, Vol.)

5 33 No. 6707 Teaching and Learning of Professionalism in medical Schools N SivalingamUK) outlines the principles of professional practice, clearlyexplaining to the public the standards of practice and carethey should expect. The main recommendations made inthe revised edition of Tomorrow s Doctors (2001) addressattitudes and behaviour that must be developed by doctorsthat would be appropriate to future responsibilities topatients, colleagues and society in of the reasons the Teaching and Learning ofprofessionalism need to be explicit, rather than remain a hidden curriculum ,7 include:1. The present system of admitting candidates based onacademic excellence alone may have little relation tothe attitude and aptitude of the student with regard to medical education is seen as a business, a career and nota noble trade and a calling.

6 3. Managed care in many countries, including Malaysia,has been implicated as an impediment to creating alearning environment. The introduction of healthinsurance by third parties with stipulations and guidelinesmay curtail the delivery of decisions based on The introduction of medical technology without impactstudies on national economy and cost-benefit ratios hascontributed to excessive investigations before elicitingan adequate history and performing a thorough physicalexamination, which negate the need for some of theseinvestigations. The latter procedures form importantcomponents of medicine that create astuteness andharmonious doctor-patient Categorising patients within a class system distinctlydiminishes encounters with senior clinicians in manydeveloping countries, together with a loss of supervisionand a lack of mentoring (a vital link in the Teaching - Learning environment), leads to a potential lowering ofthe standard of professional conduct.

7 One study onmedical errors revealed that when a mistake is made,only 24% of attending doctors notified the family and55% told their The reward system in Teaching institutions, whereemphasis is placed on publications and presentations,rather than ethics and Professionalism , has an impact onthe Learning of Task at HandIt has often been said that patients and the communityshould remain the main focus of the profession. Patientsdesire interpersonal relationships, humaneness, time forcare, skills and competence in attending doctors. Theywant to be involved in decision-making. In communitieswhere health needs and medical knowledge are poor,especially among the lower socio-economic groups, juniordoctors may take a paternalistic approach to patient a strategy is neither suave nor professional as itsimply reflects deficiencies in communication andcounselling schools should continue to emphasise the needfor improvements in communication skills and in theinculcation of the value system.

8 Patient safety is beingincreasingly emphasised through expected standards ofmedical practice. The GMC has reiterated the need for areduction in factual overload in the medical curriculum andto put more emphasis on Teaching skills in effectivecommunication. There is now more focus on preparing thepre-registration house-officer to acquire both medical andcommunication skills through Learning and shadowingsenior members of the International medical University (IMU) runs a uniquecurriculum where final-year students spend the last 6months of training in a district general hospital doing asenior clerkship, with a need to develop portfolios onclinical experience acquired throughout the period of component of the training allows for a closersupervisor-student relationship and better opportunitiesfor self-reflection and remedial action.

9 The positive valuesof this system are seen at the exit viva that the candidatestake prior to graduation. One of the 8 domains of the IMUmedical curriculum is the development of good work ethicsand the acquisition of the tenets of medical impact of the Learning activities is evaluated throughstudents reflections both at the exit viva through portfoliowriting and in the Community-Family Case Studies (CFCS),which are carried out through the clinical the Tenets of medical Ethics andProfessionalismProblem-based Learning (PBL) and clinical skillslaboratory (CSL) training, two important Teaching -learningactivities in the IMU curriculum in the first 5 semesters,provide ample opportunities for teachers to inculcateprofessionalism and ethics. This is further enhanced duringtask-based Learning and clinical ward Teaching .

10 Elementsof Professionalism can be introduced in a sequential mannerso as to have a spiralling effect as the student progressesthrough the pre-clinical to the clinical years. Attemptsshould be continuously made to internalise the tightlywoven elements of Professionalism and humaneness. Alack of explicit attention to humanistic values will invariablylead to a neglect of such values. medical education musttake cognizance of are repeatedly bombarded with traditional casewrite-ups in the clinical setting. The IMU is experimentingwith two alternative interventions in the clinical years,708 Annals Academy of MedicineTeaching and Learning of Professionalism in medical Schools N Sivalingamwhere students are rotated through various disciplines ofmedicine.