Millennials Attitude towards Medical Professionalism - A Comparative Study among Medical Students

Keywords

Attitude; Medical Training; Hidden Curriculum; Questionnaire; Humanistic.

Introduction

“Reaction or the way of being, in relation to people and objects” is defined as attitude according to the monolingual Brazilian Portuguese dictionary by Aurélio Buarque de Holanda [1]. In general, attitude is behavior that determines how individuals position themselves before people and events [2]. Professionalism is an indispensable attribute required in a medical trainee along with knowledge and clinical skills to produce talented graduates. The evolution of professional attitude and conduct begins when the candidate enters the medical institute [3]. Professional attitude also depends on a students' sense of responsibility, caring nature and reasoning skills [4].

Medical education and practice have undergone numerous changes. Scientific developments and therapeutic advances have emerged, but medicine has become fragmented, focusing more on disease than on the patients thus affecting the doctor-patient relationship [5].

These days reputed organizations are working on redefining medical professionalism. In the mid-1990’s, General Medical Council published the first edition of Appropriate Medical Training and a code of ethics while practice which was registered as "Duties of a doctor" [6], this provides a ‘gold standard’ of professional attitudes and behaviors. Principal duties include appropriate patient care, excellent communication skills, teamwork, maintaining the trust of patients in work and regularly updating professional knowledge and skills [7]. In this context, the attitudes and actions of those involved in imparting medical knowledge, right from the pre-clinical subjects, become highly significant, as they are the role models for the developing medical graduate [8]. Numerous articles have focused on particular aspects of professionalism [9], such as empathy, the ability to deal with ethical dilemmas [10, 11]. However, more documentation is necessary on the practice and application of professionalism in its broader context, on how this concept can be inculcated into daily practice as clinicians, using the ‘gold standard’ principles of good medical practice and building healthy relationships with patients and working cordially with colleagues [12].

The outlook of medical students has become an issue of concern not just within the medical fraternity but also in the general population. This reflects that training and practice of medicine cannot solely rest upon academic and technical skills but must also focus upon the character, personal integrity and what has been called the ‘humanistic idea of medicine.’ It also recognizes that unprofessional conduct cannot be managed simply by punitive measures and statements of oaths but requires formal instruction within the wider context of holistic human development [13].

The undergraduate medical curriculum is designed such that students would encounter numerous situations and expose them to a vast range of people from health care professionals, nursing staff, patients, and caretakers. This enables them to experience and inculcates attitudes, values and behavior patterns as a consequence of interaction with them. In medical courses that follow a traditional curriculum, internship is the time when students experience medical practice more intensively. In this period, the student's transition from theory-based knowledge to practical learning and application. They start discussing cases and learning the art of treating patients under the guidance of physicians, along with building on aspects such as the doctor-patient relationship. This is the stage when a young professional makes his or her identity, adopting a posture that will reflect their practice in the years to come. Based on the assumption that attitudes can be considered as predictors of behaviors and actions, evaluating students’ attitudes to relevant situations in medical practice contributes to the improvement of the training of future physicians [2, 14].

Medical training should include ethics, the ability to develop an empathic doctor-patient relationship, and social responsibility. Thus, the future medical professional must not only possess scientific medical knowledge but should be an ethical, moral and compassionate medical practitioner with a positive professional attitude. However, in contrast, there is considerable evidence that undergraduate medical education can also have a negative impact on attitudes [15]. It could increase cynical attitudes and reduce humanitarian feelings. While the point which could be argued upon is that emphasis in undergraduate medical education has been more on medical aspects, with little impact on fostering a broader and more liberal range of attitudes to social and cultural issues in medicine [16].

Thus, our study aims to evaluate and compare the millennial students’ attitudes and assess their professionalism. The results of this study will help us to take steps to integrate professionalism formally in the curriculum of undergraduate education.

Materials and Methods

The study was designed as a cross-sectional descriptive study of newly joined students - the fresher’s, batch of 2017-18 and interns, the batch of 2012-13. A questionnaire-based survey was adapted for which an online platform (Survey Monkey) was used. The respective link was sent using the WhatsApp platform and students were briefly explained the reason for conducting the research and were made aware of the confidentiality of their participation. Questions were of the agree/disagree type. Overall, 400 questionnaires were analyzed - 200 freshers and 200 interns.

Results

The cumulative findings of the survey conducted are provided in Table 1 which is self-explanatory.

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Table 1:

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Table 1. Results of the study.

Discussion

There has been substantial debate on what constitutes professionalism, with many different and frequently overlapping definitions [1-3] however no agreement has been reached; undeniably, professionalism is rooted in cultural context and is thus subject to change.

A study was done by D Peters et al., [17] on Knowledge of, and Attitudes toward Medical Professionalism among Students and Junior Doctors the junior doctor's scores were higher than the medical student's scores on the attribute of knowledge of medical professionalism, however, scores on attitude were significantly lower than medical students. There was an overall trend of decreasing attitude scores as students progressed through their training years and into clinical practice. The attitude traits included humanistic values, ethical and moral values, self-reflection, accountability and subordinating self-interest. Our study highlighted the fact that the interns, as well as the freshers, know that professionalism is learned through experience and not via textbooks. This adds support to the idea that knowledge about professionalism is drawn from experience and the power of the 'hidden curriculum' [18]. D Peters found that the two most frequent reasons for pursuing medical profession were ‘serving society’ and ‘interest’ however professionalism was not currently a major component of the medical curriculum at their medical school. He stated that majority of students enter medical school directly from high school at the age of eighteen and they do not have the benefit of formal undergraduate education, as is the case in the USA, where many of these issues of professionalism and ethics may have been highlighted, if not formally taught. D Peters in his study concluded that the medical professionals have poor theoretical knowledge about medical professionalism; although it did not indicate that their practices were unethical. Proper knowledge of this concept is one of the bases of possessing a high level of medical professionalism and for establishing a good relationship between the medical community and the patients. Improving behavior and performance in medical profession requires adequate training on the concepts of medical professionalism [17].

Medical professionalism is not a new concept and has always been present throughout the history of medicine in the form of a Hippocratic Oath taken by physicians. The key to an effective doctor-patient relationship and a successful diagnosis, treatment, and prevention of diseases is the patient’s trust in the physician [19]. In our study, a question put forth on the significance of the Hippocratic Oath and if they would be able to follow all clauses of the Oath under any circumstance brought out a positive reply. However, there were quite a lot of freshers who were unsure if they would be able to follow all the clauses of the Oath. It could be because they are unaware of the significance of the Oath.

Professional ethics prescribes that physicians should stay away from doctoring family members because of probable conflicts of interest. However, studies find that the practice is common place [20]. What do you do when your loved one is ill? The line between physician and family member. In our study both the population strongly agreed that one day they would be professional enough to operate on their family members.

Alves et al., [5] opined that students presented positive attitudes to emotional aspects of diseases, health care, and other aspects of medical activity and health. Our study showed contradictory findings where interns opined that being a medico made them insensitive towards certain emotions whereas a majority of the freshers disagreed on the same. Shahzadi Nisar Bhutto study revealed findings which were in line with ours where final year students scored higher on attributes of accountability and excellence whereas first year students mean scores were raised for altruism, duty, and integrity [21]. Health care providers and organizations require professionalism to offer guidance for decision making in difficult, ethically challenging situations. Principles of professionalism provide an orientation to the thoughts and actions of a given profession. These principles for physicians were enumerated in the Physician Charter on Medical Professionalism 13 years ago [22].

The perceptions and attitudes of medical graduates towards rural health care have a lot of significance in our setup since the Medical Council of India with the guidance of the Health ministry is planning a separate medical graduate course for the students hailing from rural setup to cater to the needs of the rural population [15]. Ragavendra et al., study revealed that a minimum percentage of Indians and Malaysians would prefer working in rural areas after graduation. The Indian students would opt for post-graduation as their next step towards advancement. Thus in many countries, India included, health situation demands that medical students should be provided with a rural clinical placement to make them familiar with basic rural service [23]. In our study students disagreed to the question posed on banning free rural service however the interns were in two minds if they would take up a job where they are needed, but the salary is less. 47.1% of them agreed on taking up the post, but 32.3% of them were unsure. The fresh batch of students were ready to take up the job irrespective of the pay. Thus this further highlights the altruistic attitude of the newly recruited graduates. In continuation of the above reflections, our students both interns, as well as fresher’s, stated that they would treat patients with the same respect regardless of their social status or ability to pay. However, Willems et al., [24] study on the socio-economic status of the patient and doctor-patient communication reported that patients from low social classes receive an indifferent consulting style characterized by giving less information, directions and emotional support. The study stated that patients from lower social classes are often at a disadvantage because of the doctor's misperception of their desire and need for information and their ability to take part in the healthcare process.

Camila et al., study on clinical communication skills and professionalism education proposed that clinical communication skills and professional competencies should be acquired at the undergraduate level. The art of leadership and interpersonal development should start during an undergraduate degree and, should be mastered during residency [25]. Our study highlighted that both groups of students- fresher’s as well as interns knew the importance of communication skills and they disagreed with the statement posted that medicines/surgery heals, whereas communication is just optional. The role of a physician and their communication skills play an essential role in patient satisfaction; therefore communication skills of physicians need to be improved through related training courses.

Another important aspect of professionalism is dealing and handling mistakes and errors. Fischer et al., stated that trainees were aware that medical errors occurs early in medical school and they had an intense emotional response to the idea of committing mistakes in patient care. While imparting knowledge to these individuals, teaching should focus on identified themes such as learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility [26]. In our study a question posed on senior colleagues\higher authorities committing an error and would the student point out the error both groups strongly agreed. They also answered positively if during operation, owing to their mistake a patient loses his life they would accept their mistake.

It has been observed that appearance, formality, and conformity is referred to as “professional” rather than traits of honor, altruism, and responsibility. This view suggests that adherence to hospital etiquette, respecting academic hierarchy, and subservience to authority are valued more than patient-centered virtues [27].

Conclusion

Professionalism is an essential component in the field of medicine which extends beyond ethics, and relevant teaching topics should include reflective practice, communication skills and relationships with colleagues and patients. The millennial doctor must possess characteristics such as trustworthiness, compassion, integrity, honesty, leadership, and social responsibility so that the future health care system will be one where patients and physicians admire and respect one another. To achieve this goal, it is important to understand how medical students today perceive professionalism and how it could be integrated into medical education. As a doctor never stops learning in his profession and needs to keep updating his knowledge so is the case with professionalism which is a life-long learning process. With the introduction of professionalism early in medical training, the future doctors will be able to provide their patients with the highest quality care.

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